Every finding on record at Advanced Rehabilitation and Healthcare of Wichita

Based on observation, interviews, and record review, the facility failed to ensure the menus were followed for 1 of 1 facility for food and nutrition services.The facility failed to follow the meal posted for lunch or dinner. The facility failed to post and follow the current week's menu in the dietary department.The facility failed to post the current week's menu where the residents can see it.This failure could result in the lack of knowledge and lead to nutritional, physical, and psychosocial upset. Findings included:In an observation on 6/27/2026 at 9:11 A.M., the menu was posted on the wall outside of the dining room and reflected as the week 4 menu. The menu showed today's lunch as cheese quesadillas, garden blend vegetables, refried beans, sugar cookies and dinner as hamburger on a bun, tossed salad, lettuce, tomatoes, pickle, potato wedges, and peach cobbler. The menu reflected today's dinner as hamburger on a bun, tossed salad, potato wedges, and peach cobbler. Record review of Resident #2's electronic health record revealed a [AGE] year-old male, admission date 01/20/2025, Diagnoses: chronic ischemic heart disease (heart damage caused by narrowed heart arteries), adult failure to thrive (state of decline that is multifactorial and may be caused by concurrent diseases and functional impairments), neoplasm of uncertain behavior of meninges (tumor that arises from the protective membranes covering the brain and spinal cord), unspecified severe protein-calorie malnutrition (imbalance between the nutrients your body needs to function and the nutrients it gets), generalized anxiety disorder (excessive, ongoing worry that is difficult to control), heart failure (heart muscle weakens or stiffens and cannot pump enough oxygen-rich blood to meet the body's needs), bipolar disorder (lifelong mental health condition that causes extreme shifts in mood, energy, activity levels, and concentration).In an interview on 6/27/2026 at 10:03 A.M. with Resident #2, he stated that sometimes the facility staff gave the wrong thing (food item) or was out of what he wanted. Resident #2 stated he ate in his room and staff come in every day to write down what he wanted for meals. Resident #2 stated he eats everything they give him or can request an alternative meal.In an interview on 6/27/2026 at 10:58 A.M. with LVN D, she stated that every morning staff take menus to the residents and let them choose their meal because the posted menu is hardly ever right. She stated the residents do not complain about the posted menu not matching the meals but do get upset if what staff tell them the morning of gets messed up.In an observation on 6/27/2026 at 12:30 P.M., the lunch plates contained lasagna, roll, cake, and salad instead of the posted cheese quesadillas, garden blend vegetables, refried beans, and sugar cookies.In an interview on 6/27/2026 at 3:51 P.M. with DC E, he stated that today's lunch was Mexican lasagna, roll, salad, and yellow cake. He stated he did not know who was responsible for posting the menu for residents. DC E stated he cooks what is posted in the kitchen by his manager to cook and he did not know what week it should be. He showed the current menu he used in the kitchen as week 3. DC E stated he had not heard any complaints from residents about the menu not being correctly posted. DC E stated dinner was polish sausage, capri vegetables, and fried potatoes. In an observation on 6/27/2026 at 3:51 P.M., the menu provided by DC E revealed week 3 menu with lasagna for lunch and polish sausage for dinner on Saturday of week 3.In an observation on 6/27/2026 at 3:51 P.M., the food being prepared was polish sausage and mixed vegetables. In an interview on 6/27/2026 at 5:13 P.M. with ADON C, she stated it was the responsibility of the kitchen staff to update and post the menu. She stated a possible negative impact on the residents could be they stop eating if it is not what they were expecting.In an interview on 6/27/2026 at 7:36 P.M. with DON B, she stated that the facility's dietary department is contracted. She stated she did not think there were any negative resident effects from the menu not being posted because staff go into their rooms daily to inform them.In an interview on 6/27/2026 at 7:36 P.M., DON B was asked for a dietary policy regarding menus. The policy was not provided prior to exit.

Based on observation, interviews, and record review, the facility failed to provide written notice to the State Agency responsible for licensing the facility at the time of change, for a change in the facility's administrator for 1 of 1 facility reviewed for administration.The facility failed to notify the State Agency of a change in the facilities administrator within 30 days.This failure could result in the lack of knowledge and inability to connect with the appropriate leadership of the facility.Findings included:In an observation on 6/26/2026 at 3:03 P.M., the name of the administrator in TULIP during offsite preparation showed a different name than ADM A. In an interview on 6/27/2026 at 10:58 A.M. with LVN D, she stated that ADM A was the administrator and she was not sure how long he had been but a while. In an interview on 6/27/2026 at 11:30 A.M. with DON B, she stated that ADM A was the administrator and had been for more than 30 days. In an interview on 6/27/2026 at 5:13 P.M. with ADON C, she revealed that ADM A was the administrator and had been for at least a couple of months, maybe even 10 months or longer. ADON C stated that ADM A was on vacation and not available. She stated that DON B was completing her administrator in training and who everyone went to in his absence. In a follow-up interview on 6/27/2026 at 7:36 P.M. with DON B, she revealed that ADM A had completed the name change in TULIP she thought because that is what he told her, but that he is not currently available. DON B stated she did not think there was any negative resident impact because they all came to her with anything and she addressed any concerns or needs. She stated that ADM A had been at the facility long enough that all staff and residents knew him and went to him, as well. Record review of the Facility Summary Report reviewed on 6/26/26 at 3:03 P.M. revealed the name of the administrator did not match ADM A.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that:1. Dietary Aide D was wearing gloves while rinsing dirty dishes and loading the dish racks for the dish machine. He stated he washed his gloves (gloved hands) before touching the clean dishes.2. The walk-in freezer had rack shelf units with open cardboard boxes/cases with bagged food items open to the air and not sealed - 1 box with enchiladas; 2 boxes with meat patties.3. The deep fryer units interior surfaces were soiled with dried and fried food crumbs and breading crumbs.4. The reach-in refrigerator had a square plastic container labeled and dated as lemon pudding 3/02/2026. The lid was warped and did not securely fit the container.5. A stainless shelf with a mesh liner was soiled with food crumbs and dust under the shelf liner.6. The non-perishable food storage room had a rack for storing large canned food items and held a row of 6.56 pound cans of tomato soup that had not been dated when delivered.7. The dry/non-perishable food storage room had an open 10 pound bag of dry spaghetti noodles had been rolled closed and put in a plastic bag that was too small for the entire package to fit into and the bag could not be sealed. There was an open package with tri-colored spiral pasta wrapped with plastic wrap.8. The second-floor satellite kitchen did not have handwashing soap and did not have a waste basket near the handwashing sink.9. The second-floor satellite kitchen's ice machine top exterior surface was lightly soiled with dust and had an empty coffee cup on its side resting on top of the ice machine. The facility's failure placed residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated. The findings included:In an interview on 3/03/2026 at 9:43 AM, the Dietary Manager stated the dietary staff were employed by a contracted culinary services agency.Observations and interviews on 3/03/2026 between 9:44 AM and 10:20 AM, during the initial tour of the first floor main kitchen, revealed the following:- Dietary Aide D was wearing black colored gloves while rinsing dirty dishes and loading the dish racks for the dish machine. He stated he washed his gloves (gloved hands) before touching the clean dishes. Dietary Aide D stated he did not have many gloves. - The Culinary Bench Manager was present in the dish room and she told Dietary Aide D that he could not wash his gloves and he needed to remove them and throw them away and put on a new pair. She stated they would get more gloves for him.- The walk-in freezer had rack shelf units with open cardboard boxes/cases with bagged food items open to the air and not sealed - 1 box with enchiladas; 2 boxes with meat patties.- The deep fryer units had dried fried food crumbs and food coating crumbs on their interior surfaces.- The reach-in refrigerator had a square plastic container labeled and dated as lemon pudding 3/02/2026. The lid was warped and did not securely fit the container.- The stainless steel shelf unit to the right of the steamer oven had mesh liner on it with inverted pans stored on the mesh liner; the surface of the shelf was soiled with food crumbs beneath the shelf liner. - The non-perishable food storage room had a rack for storing large canned food items and held a row of 6.56 pound cans of tomato soup that had not been dated when delivered.- The Culinary Bench Manager stated the cans were to be dated when delivered and rotated. She stated the undated cans were probably delivered yesterday (3/02/2026) and she would check the delivery invoice.- The non-perishable food storage room had rack shelf units. An open 10 pound bag with dry spaghetti noodles had been rolled closed and put in a plastic bag that was too small for the entire package to fit into and the bag could not be sealed. There was an open package with tri-colored spiral pasta wrapped with plastic wrap. Observation on 3/03/2026 at 10:23 AM, during the initial tour of the second-floor satellite kitchen revealed the following:- The hand washing sink had hot water and paper towels, but there was no handwashing soap or waste basket near the sink.- The ice machine top exterior surface was lightly soiled with dust and had an empty coffee cup on its side resting on top of the ice machine.In an interview on 3/06/2025 at 11:21 AM, the culinary agency's Regional Director of Operations stated he had heard about the dishwasher's comment about washing his gloves and stated the staff were in-serviced regarding handwashing and glove changes in the dish room. He stated if the dish washer washed his hands between handling the soiled dishes and putting away the clean dishes, he would not need to wear gloves. In an interview on 3/06/2026 at 11:52 AM, the culinary agency Regional Director of Operations stated an outcome from not using hand hygiene and changing gloves in the kitchen and dish room could be bad. He stated the transfer of bacteria from soiled to clean dishes could pose health risks for the residents. Record review of the culinary agency policy for Food Storage - Dry Goods, dated October 2019, indicated [in part]: Policy StatementIt is the center policy to insure [sec] all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code.Action Steps: Dry Storage5. The Dining Services Director or designee ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed.6.The Dining Services Director or designee ensures that the storage will be neat, arranged for easy identification, and date marked as appropriate. Record review of the culinary agency policy for Food Storage: Cold, dated October 2019, indicated [in part]:Policy StatementIt is the center policy to insure [sec] all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code.Action Steps5. The Dining Services Director/Cook(s) insures [sec] that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Record review of the Food and Drug Administration Food Code 2022 specified [in part]: Chapter 22-301 Hands and Arms2-301.12 Cleaning Procedure. (A)Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under Subpart 6-301.Chapter 3 Food3-202.15 Package Integrity.FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants.3-304.15 Gloves, Use Limitation. (A) If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose, FDA Food Code 2022 Chapter 3. Food 62 and discarded when damaged or soiled, or when interruptions occur in the operation. Chapter 4 Equipment, Utensils, and Linens4-602.13 Nonfood-Contact Surfaces.The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.Chapter 6 6-301 Handwashing Sinks6-301.11 Handwashing Cleanser, Availability. Each HANDWASHING SINK or group of 2 adjacent HANDWASHING SINKS shall be provided with a supply of hand cleaning liquid, powder, or bar soap. FDA Food Code 2022 Chapter 6. Physical Facilities 145 6-301.12 Hand Drying Provision. Each HANDWASHING SINK or group of adjacent HANDWASHING SINKS shall be provided with: (A) Individual, disposable towels; (B) A continuous towel system that supplies the user with a clean towel; (C) A heated-air hand drying device; or (D) A hand drying device that employs an air-knife system that delivers high velocity, pressurized air at ambient temperatures. 6-301.14 Handwashing Signage. A sign or poster that notifies FOOD EMPLOYEES to wash their hands shall be provided at all HANDWASHING SINKS used by FOOD EMPLOYEES and shall be clearly visible to FOOD EMPLOYEES. 6-301.20 Disposable Towels, Waste Receptacle. A HANDWASHING SINK or group of adjacent HANDWASHING SINKS that is provided with disposable towels shall be provided with a waste receptacle.

Based on interviews and record reviews the facility failed to readmit the resident, when the hearing officer determines that the discharge was inappropriate, the facility, uopn written notification by the hearing officer, must readmit the resident immediately, or to the next availble bed. The facility failed to readmit (Resident #1) of two Residents reviewed for discharge requirement. 1) The facility failed and refused to readmit Resident #1 from the hospital where she was transferred for evaluation and treatment. 2) The facility did not permit resident to return to the facility after the appeal ruled the facility must reverse their decision to discharge the resident. 3) The facility did not permit Resident #1 to remain in the facility for 30 days after giving her 30-day discharge notice as required. 4) There was no documentation from the physician indicating that the resident had specific needs that could not be met in the facility. 5) The facility failed to ensure transfer or discharge was documented in the resident's medical records. 6) The facility failed to establish and follow a written policy on permitting resident to return to the facility after she was hospitalized . These failures affected discharged residents and could place the residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal process. Findings Included: Record review of the face sheet for Resident #1 dated 06/18/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included overactive bladder, right leg below knee amputation, cerebral infarction (stroke), pressure ulcers, hemiplegia (severe or complete loss of strength paralysis on one side of the body), and hemiparesis (one-sided muscle weakness). Review of Resident #1's admission MDS assessment, dated 06/09/23, reflected the resident had a BIMS score of 15, which reflected the resident was cognitively intact. Section BO300 indicated adequate hearing and clear speech. Resident #1 required substantial/maximal assistance with most ADLs. Review of Resident #1's care plan dated 02/17/25 reflected Resident #1 has an ADLs self-care performance deficit and is at risk for not having her needs met in a timely manner. Record review of the appeal decision dated 03/26/25 reflected the following: APPEAL ID: 5329037 Before the Texas Health and Human Services Commission Appeals Division In the Matter § Fair Hearing Of § Decision § Appellant § § I. LEGAL AUTHORITY The fair hearing was conducted under the authority provided by Title 1, Sections 357.1 through 357.25 of the Texas Administrative Code (TAC) and related law. II. HISTORY 1. On January 16, 2025, the Agency notified the Appellant of the discharge. 2. The Appellant disagreed with the discharge and filed an appeal on February 12, 2025. 3. The Appellant did not remain in the facility because the facility refused to accept her back from the hospital she was admitted to. 4. A Notice of Hearing was mailed to Appellant on February 19, 2025, by first class mail, for a hearing scheduled for March 12, 2025. 5. The fair hearing was conducted on March 12, 2025, and the record was closed. III. FINDINGS OF FACT Finding of Fact 1: On August 6, 2024, the Appellant was admitted into the nursing facility. Finding of Fact 2: On January 16, 2025, the nursing facility issued the Appellant a notice of discharge due to nonpayment. Finding of Fact 3: The Agency did not provide the Texas Administrative Code to support the discharge; therefore, did not meet their burden of proof. IV. CONCLUSIONS OF LAW 1 TAG §357.9 states the burden of proof in a fair hearing regarding a specific issue is proof by a preponderance of evidence. The party that bears the burden of proof meets the burden if the stronger evidence, on the whole, favors that party, as determined by the Hearings Officer. The Agency or its designee bears the burden of proof in this case. Based on the findings of fact and applicable authority, the Hearings Officer concludes that: Conclusion of Law 1: Because the Agency Representative did not provide the necessary policy to support the discharge, and based on 1 TAG §357.9, Agency failed. to meet its burden of proof. Therefore, the Agency action is REVERSED. Signed this 26th day of March 2025 Lead Hearings Officer Health and Human Services Commission. Record review of the resident medical records from the month of February 2025 revealed no physician documentation on discharge of Resident #1. Record review of Resident #1 medical records from the month of February 2025 revealed Resident #1was transferred to the hospital on [DATE] for evaluation and treatment for pneumonia. She was ready to be discharge from the hospital on [DATE] but the facility refiused to take her back During interview with the RP for Resident #1 on 06/18/25 at 9:07p.m, she said she was the responsible party for Resident #1. She explained the resident had a change in condition after fall from her wheelchair. According to the resident, she was on the floor for more than an hour before the facility responded to the fall. Resident #1 was transported to the hospital for evaluation and treatment due to severe pain from the fall. The RP stated after resident was stabilized in the hospital, the facility refused to take the resident back from the hospital due to non-payment. She explained the facility failed to fill papers with Medicaid to receive the necessary services. The family was advised to file appeal with HHSC. They filed the appeal which concluded that the facility must readmit Resident #1 to the facility. The facility refused after several attempts to come back to the facility, they decided to go to another facility. The RP explained the facility filed a lawsuit against the resident for non-payment. The RP stated that the Facility Administrator stated, the facility will never take the resident back and he don't care what the State said. In an interview with the BOM on 06/18/25 at 10:31a.m, she said she was the Business Office Manager for the facility. She Stated she was familiar with Resident #1. The BOM explained the resident was given 30-day notice but was transferred to the hospital for evaluation and treatment. She noted the resident was sent to the hospital few days before the 30-day notice ended. She stated the resident was not allowed to return to the facility for non-payment. The resident was owing more than $44,000. The BOM explained the resident and family refused to submit necessary documentation to apply for Medicaid as required. She was made aware that the family sold the resident's house and did not deposit the money on her account. The BOM stated she was not aware resident had an appeal with HHSC until the surveyor brought it to her notice. She noted she was not aware of any attempt to get the resident back to the facility. During interview with the DON on 06/18/25 at 1:41p.m, she stated she was familiar with Resident #1. The DON explained resident fell and was transferred to the hospital for further evaluation and treatment. She stated the facility notified the hospital of their intention not to readmit the resident for non-payment. She noted Resident #1 and family was non-complaint in providing required documentation Medicaid payor source approval. They kept holding information and stated they were switching to private pay. The Family did not make payment and was owing more than $44,000 in non-payment. The DON stated she was not aware of an appeal to stay in the facility by Resident #1. She said the Administrator may know but he was no longer employed by the facility. She noted the resident was given 30-day notice but was transferred before the end of the notice. Record review of notice letter dated 01/16/25 revealed Resident #1 was given a 30-day notice leave the facility. Record review of the facility policy on Admission, Transfer and discharge date d 10/10/17 reflected: Policy Statement This facility complies with federal regulations to permit each resident to remain in the facility, and not transfer or discharge unless the following criteria is met: Fundamental Information 1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. 2. The transfer or discharge is appropriate because the president's health has improved sufficiently so the resident no longer needs the service provided by the facility. 3. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. 4. The health of individuals in the facility would otherwise be endangered. 5. Respite residents are discharged based upon the agreed length of stay and plan of care 6. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility; or 7. The facility ceases to operate. Policy Explanation and Compliance Guidelines: The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs. 2. The facility permits each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. 3. The facility may initiate transfers or discharges in the following limited circumstances: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. The residents' health has improved sufficiently so that the resident no longer needs the care. and/or services of the facility. c. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. d. The health of the individuals in the facility would otherwise be endangered. e. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility. f. The facility ceases to operate. 4. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. 5. When a resident exercises his or her right to appeal a transfer or discharge, the facility will not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.

Based on interviews and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 1 resident (Resident #2 reviewed for discharge requirements. The facility failed to readmit Resident #2 after being admitted to the hospital, while facility initiated discharge was Pending Appeal. This failure placed residents at risk of not receiving necessary care and services. . Findings included: Record review of Resident #2's Face Sheet dated [DATE], reflected Resident #2 was a [AGE] year-old female, admitted to facility on [DATE]. Diagnoses included aftercare following surgical amputation below right knee, hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (weakness and/or loss of strength to one side), type 2 diabetes (insulin resistance and high blood sugar levels), major depressive disorder (mood disorder that causes persistent feeling of sadness and loss), cerebral infraction (stroke), pressure ulcer of sacral region stage 3 (deeper involvement of underlying tissue with more extensive destruction spine tissue). Record review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 has BIMS score of 15 (cognitively intact). Resident #2 needs extensive assistance with bed mobility, transfers, toileting, and dressing. Record review of Resident #2's Care Plan dated [DATE] revealed the resident had an indwelling catheter, ADL Self Care Performance Deficit, diagnosis of major depressive disorder, diagnosis of diabetes, fall risk, right heel MRSA, Enhanced Barrier Precautions d/t Urinary catheter, psychotropic medications antidepressants, anxiolytics related to depression. Record review of Resident #2's medical record revealed that Resident #2 fell in her room on [DATE], resident was assessed by facility staff and sent to hospital for further evaluation. Resident #2 did not suffer any injury due to fall but was diagnosis with pneumonia. On [DATE] hospital contacted nursing facility stating resident was ready for discharge back to the nursing facility. Facility refused to accept resident back due to non-payment for care at facility. Interview on [DATE] at 11:40 am, BOM stated that Resident #2 admitted to facility on [DATE] from LTAC. Resident #2 had Blue Cross Blue Shield (BCBS) Cobra insurance. Facility was notified by BCBS in September that Resident #2's coverage had expired; Resident #2 had run out of covered days before admitting to facility. Resident #2 and Resident #2's POA were informed that her stay would be private pay until Medicaid, or another payor source was found. BOM stated that POA stated will apply for Medicaid. Resident #2 was denied Medicaid due to 'not meeting eligibility'. BOM stated that Resident #2 must apply for SSI before being approved for Medicaid. BOM stated resident had not applied for SSI and is not MCD pending. BOM stated that the facility does not take SSI pending residents and that BOM informed Resident #2 and POA. BOM stated on [DATE], Resident #2 paid $5456 for [DATE] stay, and on [DATE] paid $4,752 for [DATE] stay. BOM stated that Resident #2 had an outstanding balance of $44, 572.82, which Resident #2 and POA stated they cannot pay. Interview [DATE] at 10:30 am, Resident #2's POA stated that Medicaid was applied for, but was denied on [DATE] due to Medicaid saying Resident #2 owned two houses; one in Dallas and one in Wichita Falls. POA stated the house in Dallas was sold in [DATE], and the money was used to buy house in Wichita Falls. POA stated that Resident #2 did not have Social Security, but they are applying for disability (SSI). POA was informed by facility that resident must have SSI before applying for Medicaid, and that the facility does not take SSI pending, and that the resident must be private pay. POA stated that Resident #2 cannot pay private, that was why they are trying to get Medicaid. POA stated that she and Resident #2 received a 30-day Notice of Discharge from facility on [DATE], with effective discharge date of [DATE]. POA stated an appeal of discharge was made on [DATE], and the Fair Hearing was set for [DATE]. POA stated that the facility has refused to readmit Resident #2 back from the hospital. POA stated they have no place for Resident #2 to go. Interview on [DATE] at 1:20 pm, Administrator stated on [DATE], he issued a 30-Day Discharge Notice to Resident #2, Resident #2 's POA, Resident's primary physician, and Ombudsman. Administrator stated that Resident #2 had an outstanding bill of $44,572.82, has no coverage days with his medical insurance, and is not MCD eligible. He stated Resident #2 is applying for SSI, and they do not accept SSI pending. Administrator stated he was notified that the Discharge Notice was appealed and that the Fair Hearing was set for [DATE] and that he plans to attend hearing. Administrator stated the facility was contacted by the hospital and he refused to readmit Resident #2 back in facility. Administrator stated his reason for denial was Resident #2 has no payor source, an outstanding bill of $44,572.82, and Resident #2 and her POA have stated they cannot pay. Record review of facility's Admission Policy dated [DATE], revised [DATE], revealed: Policy Explanation and Compliance Guidelines, 5). When a resident exercises his or her right to appeal a transfer or discharge. That facility will not transfer or discharge the resident while the appeal is pending unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.

Based on interview and record review, the facility failed to ensure the right to be free from verbal abuse for 1 of 1 resident reviewed for mistreatment, (Resident #1). On 02/02/25 at 1:00 pm, LVN A began arguing with Resident #1. LVN A continued arguing after being asked to stop by other staff repeatedly, and continued to anger and upset Resident #1. This failure could place residents at risk for resident mistreatment. Findings included: Record review of Resident #1's Face Sheet dated 2/27/25 revealed a [AGE] year-old female, admitted to facility on 5/23/22 with diagnoses that included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems without behaviors), ); Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), obesity, generalized anxiety disorder (worry, excessively and feel nervous or restless for no obvious reason). Record review of Resident #1's MDS assessment dated [DATE], revealed Resident #1 had BIMS score of 15 (cognitively intact). Record review of Resident #1's Care Plan dated 12/4/24 indicated Resident #1, schizophrenia, ADL deficit-forgetfulness, confusion, behaviors-sexual comments with males, history of false allegations, trauma while in state facility, verbally abusive behaviors, anxiety, anti-psychotic med, psychotropic medications (antidepressants, antipsychotics, anxiolytics, or hypnotics) related to depression, generalized anxiety disorder, schizophrenia- Has EPS from antipsychotic usage-tremors of hands. Interventions are to calm voice when speaking to resident and redirect when resident agitated. Record review of intake On 02/02/25 around 1:00 pm Resident #1 and LVN A had a verbal altercation where Resident #1 called LVN A fat and then LVN A told Resident #1 that she was Fat and Ugly. LVN A was suspended and after facility investigation terminated. Record review of statement provided by LVN A to Administrator dated 02/02/25, LVN A stated that resident called me fat, I did say she was ugly, referring to her calling me fat. I told her God does not like ugly, resident said I bet you and your wife do it doggy style you son of a bitch. Interview on 02/27/25 at 10:00 am, Resident #1 stated she was talking to RN B at nurse's station and LVN A started running his fat mouth. She stated that she said he was a [NAME] and fat, and she called him a bastard. LVN A said she was ugly and flipped me the bird. RN B told him to stop but LVN A kept on talking and calling her ugly, RN B and Resident #1 left. She was so upset, she was shaking. Resident #1 stated that she was doing well since the Administrator got rid of LVN A. Resident stated that she knows her rights and staff are not allowed to call residents names. Interview on 02/27/25 at 10:20 am, RN B stated she was witness to incident on 02/02/25. RN B stated she was at the nurse's station when Resident #1 came up and started taking to RN B. RN B stated all was fine just a general conversation. RN B stated that LVN A just butted in on conversation and that upset Resident #1. She told Resident #1 not to worry about LVN A and then Resident #1 called LVN A a fat [NAME]. LVN A said Resident #1 was ugly, and they both started bickering at one another very loudly. RN B stated she stepped in, tried to redirected Resident #1, and told LVN A to stop, but LVN A continued bickering with Resident #1 even after RN Basked LVN A many times to stop. RN B stated she was able to separate Resident #1 away from LVN A and started walking away, stating LVN A continued bickering and upsetting Resident #1 further. RN B stated protecting resident was her only concern and to stop the bickering. RN B stated it was very loud and disruptive. RN B stated once Resident #1 was calm and safe, RN B stated she immediately reported the incident to Administrator. Interview on 02/27/25 at 10:55 am, CNA C witnessed incident on 02/02/25. CNA C stated she was not positive on how conversation started between LVN A and Resident #1. CNA C stated she heard Resident #1 raising her voice towards LVN A and LVN A raising his voice. CNA C stated she heard LVN A say that Resident #1 was fat & ugly, and Resident #1 called LVN A fat and that he'eats four meals a day CNA stated that RN B was separating Resident #1 and LVN A. RN B asked LVN A several times to stop, but LVN A did not, and keep arguing with Resident #1. CNA C stated Resident #1 was clearly upset and LVN A should have stopped aggravating her. Several attempts made to contact LVN A was unsuccessful. 2/27/25 at 4:15pm, no voice mail, 2/28/25 at 8:55am, no voice mail. 2/28/25 at 2:10pm, no voice mail. Interview on 02/27/25 at 11:50am, Administrator stated that he is the facility's Abuse Coordinator, and the facility does not tolerate staff getting into verbal arguments with residents. Administrator stated his expectation that always for staff to be respectful and professional. Administration stated that LVN A was aggravating Resident #1 with little regards to Resident #1's mental diagnosis. Administrator stated that LVN A was terminated for Verbal Abuse. Record review of LVN A employee file revealed he was hired 4/23/21. There was a disciplinary write-up dated 3/3/23 for 'Speaking to resident in stern voice'. LVN A's annual background check dated 04/03/24 training for Abuse, neglect and Resident's Rights were up-to date. Review of the facility's Abuse, Neglect and Exploitation policy., dated 10/24/22, revised 9/6/24 Reflected, Policy: Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

Based on observation, interviews, and record reviews, the facility failed to provide an appetizing temperature meal for 3 of 3 residents reviewed for meal palatability. The facility failed to serve meals at palatable, attractive, and at an appetizing temperature for residents #105, #25 and #27 served their meals in their rooms. This failure could affect the residents by placing them at risk for malnutrition due to not providing appetizing temperature meal. Findings included: An observation and interview with the Dietary Manager on 12/05/24 at 11:58 AM, in the Satellite Kitchen on the 2nd floor revealed: A. The holding temperatures were as follows: Turkey Entre 169.2 Fahrenheit and Carrots 174.1 Fahrenheit. B. At 11:59 AM, the sample tray was placed on the food cart. C. At 12:07 PM, the food cart left the kitchen. D. At 12:12 PM, the last tray was delivered to the resident. E. At 12:15 PM, the sampled tray was tested with the Dietary Manager. The temperature of the food was as followed: Turkey entre 100 Fahrenheit and the carrots 104 Fahrenheit. The surveyor team and the Dietary Manager all tasted the food. The food was rated as lukewarm The Dietary Manager stated the food was not warm enough. In an observation and interview with the Dietary Manager on 12/05/24 at 12:50 PM, in the Main Kitchen on the 1st floor: A. The holding temperatures were as follows: Turkey Entre 167.2 Fahrenheit and Carrots 158.6 Fahrenheit. B. At 12:52 PM, the sample tray was placed on the food cart. C. At 12:56 PM, the food cart left the kitchen. D. At 1:00 PM, the last tray was delivered to the resident. E. At 1:01 PM, the sampled tray was tested with the Dietary Manager. The temperature of the food was as followed: Turkey entre 132 Fahrenheit and the carrots 131 Fahrenheit. The surveyor team and the Dietary Manager all tasted the food. The food was rated as warm The Dietary Manager stated the food was warmer than the 2nd floor. During an interview on 12/04/24 at 11:35 AM, Resident #105's family member stated Resident #105 ate in his room and the food was cold most of the time. During an interview on 12/04/24 at 11:57 AM, Resident #25 stated she ate mostly in her room and the food was cold. During an interview on 12/04/24 at 11:48 AM, Resident #27 stated she ate in her room most of the time and stated I get cold food quite a bit. Record review of the Resident Council meeting minutes revealed on 10/02/2024, 09/04/24, 08/07/24, 07/03/24, 05/01/24, 04/02/24, and 03/06/24, the residents complained of cold food. In an interview and record review on 12/06/24 at 10:57 AM, the Dietary Manager and Dietician, stated they received reports from Resident Council that the food being served to the residents' rooms was cold. The Dietary Manager stated, as a result, they had been checking food temperatures monthly and that the food temperatures were ok. They said there was no documentation of testing the temperatures of the food. The Dietician said a potential negative outcome of hot foods not being served hot were the residents might not eat their food causing hunger and weight loss. A facility policy was requested regarding food temperatures and was provided the policy Food Safety and Sanitation Plan,. However, the policy failed to address residents receiving cold foods. The Dietary Manager said there was no other policy. In an interview on 12/06/24 at 12:00 PM, the Administrator said cold food had been the number one complaint he received from the residents, and the facility has been working on addressing the cold food temperatures but nothing has worked so far. He said QAPI has identified it, and is currently being worked on. Record review of the facility policy Food Safety and Sanitation Plan, dated as last reviewed on 11/28/17 revealed the policy did not provide any relevant references to the failure.

Based on observation, interview, and record review, the facility failed to ensure it was free of medication error rates of five percent or greater. There were 4 medication errors out of 28 opportunities, resulting in a medication error rate of 14% involving 4 of 10 residents (Resident #s #151, #113, #39, & #80) reviewed for medication errors. A. On 12/4/24 at 11:29 am, LVN A administered Micafungin Sodium IV to a Resident #151 at the incorrect physician ordered administration time. B. On 12/4/24 at 11:38 am, LVN A failed to prime the insulin needle prior to administering Novolog 100 units/ml via a Flex Pen to Resident #113. C. On 12/4/24 at 11:44 am, LVN A failed to prime the insulin needle prior to administering Humalog 100 units/ml via a Flex Pen to Resident #39. D. On 12/4/24 at 11:51 am, LVN A failed to prime the insulin needle prior to administering Novolog 100 units/ml via a Flex Pen to Resident #80. These deficient practices could place residents at risk of not receiving their medications according to physician's orders and cause a physical decline in health. The findings included: 1. Record review of Resident #151's Admission Record dated 12/06/2024 revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with the following diagnoses: Aftercare Following Joint Replacement Surgery, Unspecified Asthma Uncomplicated (airway restriction), Multiple Sclerosis (breakdown of the protective covering of nerves), Other Migraine, Intractable Without Status Migraineurs (severe headaches), Presence of Right Artificial Hip Joint, Other Idiopathic Peripheral Autonomic Neuropathy (nerve pain), Herpes viral Vesicular Dermatitis (skin inflammation), Vitamin Deficiency, Attention Deficit Hyperactivity Disorder (attention difficulty), Gastro Esophageal Reflux Disease without Esophagitis (heart burn), Muscle Spasms, Anemia (low red blood cells), Depression, Anxiety, Insomnia (difficulty sleeping), Hypertension (high blood pressure), and Age Related Osteoporosis Without Current Pathological Fractures (weak and brittle bones). Record review of Residents #151's Physician orders revealed the following medication orders, dated 12/06/2024 revealed: 1. Micafungin Sodium IV Solution 100 mg use 10 mg IV one time a day at 7:00 PM In an observation on 12/4/24 at 11:29 am, LVN A administered Micafungin Sodium IV to a Resident #151. 2. Record review of Resident #113 Admission Record dated 12/06/2024 revealed that she was an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Fracture with Routine Healing, Type II Diabetes Mellitus Without Complications (diabetes), Asthma (difficulty breathing), Zoster Without Complications (shingles), Hypothyroidism (underactive thyroid), Hyperlipidemia (elevated lipids in blood), Major Depressive Disorder (chronic depression), Generalized Anxiety Disorder (anxiety), Hypertension (high blood pressure), Allergic Rhinitis (seasonal allergies), Gastro Esophageal Reflux Disease Without Esophagitis (heart burn), and Urinary Tract Infection (infection of the bladder). Record review of Resident #113's physician orders dated 12/06/2024 revealed the following medication orders: 1. NovoLOG FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML Inject 2 unit subcutaneously with meals for diabetes 2. NovoLOG FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML Inject as per sliding scale: if 150 - 224 = 1 unit; 225 - 299 = 2 units; 300 - 374 = 3 units; 375 - 449 = 4 units; 450 - 500 if >450, give 5 units and notify the physician, subcutaneously before meals. In an observation on 12/4/24 at 11:38 am, LVN A failed to prime the insulin needle prior to administering Novolog 100 units/ml via a Flex Pen to Resident #113. Record review of Resident #39's Admission Record dated 12/06/2024 revealed that she was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Depressed (depression), Unspecified Systolic Congestive Heart Failure (heart failure), Hypokalemia (low potassium), Non ST Elevation NSTEMI Myocardial Infarction (heart attack), Mixed Hyperlipidemia (elevated lipids in the blood), Polyneuropathy (nerve pain), Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris (plaque buildup in arteries), Peripheral Vascular Disease (narrowed blood vessels),Complete Traumatic Amputation At Level Between Knee and Ankle Left Lower Leg Initial Encounter (left leg amputation), Hypertension (high blood pressure). Record review of Resident#39's physician orders dated 12/06/2024 revealed the following medication orders: 1. HumaLOG Injection Solution 100 UNIT/ML 2 unit subcutaneously before meals 2. HumaLOG Injection Solution 100 UNIT/ML as per sliding scale: if 150 - 189 = 1 unit;190 - 229 = 2 units; 230 - 269 = 3 units; 270 - 309 = 4 units; 310 - 349 = 5 units if BBG IS GREATER OR EQUAL TO 350, GIVE 5 UNITS AND ALERT MD, subcutaneously before meals and at bedtime In an observation on 12/4/24 at 11:44 am, LVN A failed to prime the insulin needle prior to administering Humalog 100 units/ml via a Flex Pen to Resident # 39. Record review of Resident #80's Admission Record dated 12/06/2024 revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Sepsis Unspecified Organism (blood infection), Insomnia (difficulty sleeping, Iron Deficiency Anemia (low iron), Type II Diabetes Mellitus Without Complications (diabetes), Vitamin D Deficiency (low vitamin D), Hyperlipidemia (elevated lipids in the blood), Hypertension (high blood pressure), Heart Failure, Peripheral Vascular Disease (narrowed blood vessels), Chronic Pulmonary Disease (blocked airflow in the lungs), Gout (arthritis in joints), and COVID -19. Record review of Residents #80's physician orders dated 12/06/2024 documented the following medication orders: 1. NovoLOG FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML 5 unit subcutaneously with meals 2. NovoLOG FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML as per sliding scale: if 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units; 400 - 450 = 12 units if BBG >400, give 12 units and notify physician, subcutaneously before meals and at bedtime. In an observation on 12/4/24 at 11:51 am, LVN A failed to prime the insulin needle prior to administering Novolog 100 units/ml via a Flex Pen to Resident # 80. In an interview on 12/6/24 at 8:30 AM regarding Residents #113, 39, and 80, LVN A stated, I take off the primed needle then put on a new needle. You prime the needle to make sure the pen is good. There is not insulin in the new needle . She was unable to explain correct medication administration of priming needle with insulin prior to administering. She did not acknowledge that replacing the primed needle with a new needle, and failing to prime that needle, can cause any adverse reactions or that failure to do so, prevents the resident from receiving the entire dose of insulin. She acknowledged that the nurse is responsible for ensuring insulin administration is conducted properly. In an interview with LVN A 12/06/2024 at 11:15 am, when asked if she reviewed the MAR prior to administrating Resident #151's IV on 12/04/2024 at 11:29 am, she stated the medication was on the MAR but had a time order change the day previous. She stated that upon review the medication was scheduled at 7:00 PM. LVN A stated lack of checking orders and following rights of medication administration could cause someone to get something they aren't supposed to get. She further stated to prevent medication errors in the future, you should check the order before giving it. She stated, The nurse who passes the medication are responsible for checking medication and that, missing that final check caused that error. In an interview on 12/6/24 at 3:50 pm, the DON stated, My expectation is for them (staff) to follow their MAR and go by their MAR which is time limit is specific . She further stated that she does acknowledge that the nurse administered the Micafungin at 11:29 am and that the physician order at that time was for 7:00 PM. She stated an adverse outcome of not following a physician's order could lead to anaphylaxis, renal failure, or heart failure. She stated the administering nurse is responsible for checking the MAR and administering medications. The DON stated, The nurses should prime the needles prior to administration. She stated that primed needles should not be replaced prior to injection. They have skills check offs and annual checks off for all of that. She continued to say that she spoke with the nurse who removed the primed needle and replaced it with a non-primed needle and educated her on how to properly prime an insulin needle. She stated hyperglycemia (high blood sugar) could be a result of not priming the insulin pen needle. Record review of the facility's policy and procedure guide labeled Administration of IV Fluids and Medications, dated April 2014, revealed the following [in part]: .Procedure: 1. Verify label on IV bag with prescriber's order . Record review of the facility's policy and procedure labeled License Skill Review for Administration of SQ Insulin via Insulin Pen provided by the DON on 12/6/2024 revealed the following [in part]: .5. Prepares injection: o Attaches the needle o Remove the needle cap o Check the flow of delivery device (air shot) o 2-unit PRIIME every time o Select the dose prescribed .

Based on interviews and record review, the facility failed to implement its policies and procedures to prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property for 4 of 4 staff members (ADM, DON, ADON and CNA B) reviewed for abuse protocol. The facility failed to complete annual Criminal Background Checks for the ADM, DON, ADON and CNA B. This failure could place residents at risk for abuse, neglect, and exploitation. Findings included: Record review of the ADM personnel file revealed no annual criminal background check completed for 2024. The ADM had a hire date of 5/9/2016. Record review of the DON personnel file revealed no annual criminal background check completed for 2024. The DON had a hire date of 1/19/10. Record review of the ADON personnel file revealed no annual criminal background check completed for 2024. The ADON had a hire date of 06/23/04. Record review of CNA B personnel file revealed no annual criminal background check completed for 2024. CNA B had a hire date of 12/19/20. In an interview on 12/6/24 at 3:26 PM, ADM stated that annual background checks for 2024 were not completed on any employee with a hire date prior to 1/1/24 by the Human Resources Manager. He stated that he was not aware the checks were not being run and that the Human Resources Manager would run them 12/6/24. He stated that employees hired within year 2024 had background checks completed. In an interview on 12/6/24 at 5:10 pm, the Human Resources Manager stated, I ran them, but I cannot find them referring to annual criminal background checks for year 2024. She stated that it was her responsibility. She stated, I don't know when asked about adverse outcome of checks not being run. She also stated that she was not aware that she needed to keep previous checks on file. She stated that she ran them in January of 2023, but was unsure of the exact date . In an interview on 12/6/24 at 5:23 PM, the ADM stated that criminal background checks should be ran annually in January per policy and completed before hire. He further stated that an adverse outcome of not running employee background checks could lead to having staff with felonies. Record review of facility policy Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/22 revealed the following [in-part]: Policy Explanation and Compliance Guidelines: .3. The facility provides ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The components of the facility abuse prohibition plan are discussed herein: I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 3. The facility will maintain documentation of proof that the screening occurred. Record review of facility Human Resources Policies and Procedures Manual revised 07/09, section 7. Safety and Health, Subject-Applicant and Employee Screening revealed the following [in-part]: Policy: All current employees will have annual employee screening conducted. 2. Criminal history check will be completed. Criminal History: Criminal history checks must be completed prior to employment and annually, each January thereafter for all staff and volunteers.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 33 residents (Residents #39) reviewed for infection control. The facility failed to ensure LVN A donned (put on) Personal Protective Equipment (PPE), as required for residents who were on transmission-based precautions (TBP), when she entered Resident #39's room. This failure could place residents at risk for infections. The findings include: 1. Record review of Resident #39's face sheet, dated 12/05/2024, revealed a [AGE] year-old female, who was admitted to the facility on [DATE] with the following diagnoses osteomyelitis (bone infection), essential hypertension (high blood pressure), type 2 diabetes mellitus (diabetes), and chronic obstructive pulmonary disease (lung disease). Record review of Resident #39's MDS assessment dated [DATE] revealed the following: Section O: Special Treatments, Procedures and Programs performed: M1. Isolation or quarantine for active infectious disease while a resident. Record review of Resident #39's Care Plan, initiated on 11/14/24, revealed a care plan for MRSA and resident on contact isolation due to infection. Record review of Resident #39's physician orders, active date of 12/04/2024, revealed Resident #39 had an order for Contact Precautions for diagnosis of MRSA in effect every shift with order start date of 11/14/2024 and no end date. An observation on 12/04/2024 at 2:01 PM revealed, Resident #39's door was closed, there were PPE supplies hanging on the outside of door, and Contact Precaution signage which informed the viewer that the resident was on Contact Precautions. The contact precautions sign revealed: Perform hand hygiene before entering and before leaving room, Wear gloves when entering room or cubicle and when touching patient intact skin, surface, or articles in close proximity, Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient's items or potential contaminated environment, Use patient-dedicated or single use disposable shared equipment or clean and disinfect shared equipment. LVN A was observed entering Resident #39's room without donning PPE, then closed Resident #39's door. LVN A was then observed leaving Resident #39's room without PPE on 12/4/24 at 2:03 PM. In an interview on 12/4/24 at 2:03 PM, LVN A stated that Resident #39 was on contact precautions due to MRSA in her wound. She further stated that PPE was to be used only when we do care or mess with the wound . She stated that the staff didn't need to put PPE on for entering Resident#39's room for other resident care. Further stating, staff only need to wear PPE such as gown when in contact with the resident's wound . In an interview on 12/4/24 at 2:09 PM, ADON B stated that Resident #39 was on contact precautions. She also stated that her expectation is staff should only put on PPE if in direct contact with resident's wound. In an interview on 12/5/24 at 2:42 PM, the DON stated that Resident #39 is currently on contact precautions. The DON also verified the physician's order, care plan, MDS, and that the sign posted on Resident #39's door is for contact precautions. The DON stated that her expectation, for any resident on contact precautions, is for staff to don (put on) PPE, gown, and gloves, upon entry into resident's room. She also stated that lack of following ordered contact precautions could lead to spread of infection. Record review of facility policy Transmission-Based (Isolation) Precautions dated 10/24/22 revealed the following [in-part]: Contact Precautions - refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. 8. Contact Precautions - a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens.

Based on observations, interviews, and record reviews, the facility failed to provide supervision to prevent accidents for 1 of 3 residents (Resident #s 1) whose care was reviewed in that: The facility failed to implement ADL transfer interventions for Resident #1 . This failure could affect residents that required assistance with transfers. The findings were: Review of the Resident #1's Facesheet, dated, 05/09/2024, revealed she was admitted on [DATE], with diagnoses that included: hypertension (high blood pressure), Diabetes Melitus (too much sugar in the blood) difficulty in walking, and dementia (loss of memory). Review of Resident #1's Admission MDS, dated [DATE] revealed the following: Section C revealed resident's BIMS was a 06 (severe cognitive impairment). Section GG revealed resident partial/moderate assistance with transfers. Review of the Resident #1's Care plan dated 05/06/2024 revealed the following: -Resident #1 has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: diagnosis of dementia (loss of memory). - Resident #1 has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner and will require transfers with extensive assist x 1 staff (help resident). During an observation on 05/09/2024 at 11:30 AM, a video clip that was provided from the facility of Resident #1's room revealed that CNA A placed wheelchair to the left of Resident #1 in a 90-degree angle from the bed. CNA A stepped behind the wheelchair. Resident #1 stood from bed without staff assistance and CNA A could be heard asking Resident #1 to turn a little. Resident began turning to the left and fell to the left between the bed and the wheelchair. CNA A immediately called for help and assisted the resident. During an observation on 05/10/2024 at 1:30 PM., Resident #1 was lying in her bed watching TV, she stated that she could transfer without assistance. She stated that, does not remember much but that she lost her balance and fell . She revealed that CNA A was always nice to her and kind and that she liked it when she worked. She stated that she knows how to press her call light, but she does not always press it because she does not always need help. During an interview on 05/10/2024 at 9:00 AM., CNA A revealed that, the day Resident #1 fell the following occurred, the resident had pulled her light, she was sitting up on the side of her bed and was needing to go to the bathroom, the CNA asked if Resident #1 wanted to use her walker or wheelchair. The resident said she wanted to use her wheelchair. CNA A said that she pulled the wheelchair next to Resident #1 and the bed and locked the wheels, but when Resident #1 stood up, she faced the chair. CNA A told Resident #1 that she needed to turn around so she could sit in the chair. She stated that when Resident #1 turned to sit correctly in the chair, that is when Resident #1 fell . She said that after Resident #1 fell , she made sure Resident #1 was okay, and she immediately got the nurse. She said she was sitting with her and making sure she was okay until the nurse got there. CNA A stated that she did not know Resident #1 required assistance with transfers, she thought Resident #1 was supervision because the resident gets up on her own and walks on her own and that is what she was before. She stated that she had not ever looked at her care plan, but she should have. CNA A stated Resident #1 often stands and transfers by herself, so she assumed Resident #1 could still do that. She stated that this failure could result in the resident falling and hurting herself. During an interview on 05/10/2024 at 10:30 AM., CNA B revealed that, Resident #1 had been transferring by herself. Staff had been telling her to call for assistance, but Resident #1 had not been doing that. She stated that the facility staff placed a sign on the resident's wall to even remind her. She stated that she would walk in her room, and Resident #1 would be in her bathroom. She revealed that she often worked the hall that the resident was on, and that Resident #1 thought she was independent. She stated that she knew how to access the care plans for each resident. During an interview on 05/10/2024 at 10:45 AM., CNA C revealed that Resident #1 had been transferring by herself, even though staff asked her not to, she still would. She stated that Resident #1 used to transfer without assistance, and she still thought that she could. She stated that they would take Resident #1 to the bathroom, and she would ask facility staff to leave and then would transfer back to her wheelchair by herself. She stated that she knew how to look up the care plans. During an interview on 05/10/2024 at 11:30 AM., the DON confirmed Resident #1 required assistance x1 with transfers. Her expectations were that all staff review the care plans that are individualized to each resident and that covers their needs. She revealed that this resident was able to transfer with supervision previously, but that she required assistance with transfers at the time of the fall. A copy of the policy related to Care Plans was requested on 05/10/2024 at 1:00 PM, the facility stated that they use the RAI manual for guidance on Care Plans. Record review of CMS RAI Version 3.0 Manual last revised October 2023 revealed: the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment.

Based on observations, interviews, and record reviews, the facility failed to implement care interventions in accordance with each resident's written plan of care for 1 of 3 residents (Resident #s 1) whose care was reviewed in that: The facility failed to implement ADL transfer interventions for Resident #1 as care planned. This failure could affect residents that required assistance with transfers. The findings were: Review of the Resident #1's Facesheet, dated, 05/09/2024, revealed she was admitted on [DATE], with diagnoses that included: hypertension (high blood pressure), Diabetes Melitus (too much sugar in the blood) difficulty in walking, and dementia (loss of memory). Review of Resident #1's Admission MDS, dated [DATE] revealed the following: Section C revealed resident's BIMS was a 06 (severe cognitive impairment). Section GG revealed resident partial/moderate assistance with transfers. Review of the Resident #1's Care plan dated 05/06/2024 revealed the following: -Resident #1 has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: diagnosis of dementia (loss of memory). - Resident #1 has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner and will require transfers with extensive assist x 1 staff (help resident). During an observation on 05/09/2024 at 11:30 AM, a video clip that was provided from the facility of Resident #1's room revealed that CNA A placed wheelchair to the left of Resident #1 in a 90-degree angle from the bed. CNA A stepped behind the wheelchair. Resident #1 stood from bed without staff assistance and CNA A could be heard asking Resident #1 to turn a little. Resident began turning to the left and fell to the left between the bed and the wheelchair. CNA A immediately called for help and assisted the resident. During an observation on 05/10/2024 at 1:30 PM., Resident #1 was lying in her bed watching TV, she stated that she could transfer without assistance. She stated that, does not remember much but that she lost her balance and fell . She revealed that CNA A was always nice to her and kind and that she liked it when she worked. She stated that she knows how to press her call light, but she does not always press it because she does not always need help. During an interview on 05/10/2024 at 9:00 AM., CNA A revealed that, the day Resident #1 fell the following occurred, the resident had pulled her light, she was sitting up on the side of her bed and was needing to go to the bathroom, the CNA asked if Resident #1 wanted to use her walker or wheelchair. The resident said she wanted to use her wheelchair. CNA A said that she pulled the wheelchair next to Resident #1 and the bed and locked the wheels, but when Resident #1 stood up, she faced the chair. CNA A told Resident #1 that she needed to turn around so she could sit in the chair. She stated that when Resident #1 turned to sit correctly in the chair, that is when Resident #1 fell . She said that after Resident #1 fell , she made sure Resident #1 was okay, and she immediately got the nurse. She said she was sitting with her and making sure she was okay until the nurse got there. CNA A stated that she did not know Resident #1 required assistance with transfers, she thought Resident #1 was supervision because the resident gets up on her own and walks on her own and that is what she was before. She stated that she had not ever looked at her care plan, but she should have. CNA A stated Resident #1 often stands and transfers by herself, so she assumed Resident #1 could still do that. She stated that this failure could result in the resident falling and hurting herself. During an interview on 05/10/2024 at 10:30 AM., CNA B revealed that, Resident #1 had been transferring by herself. Staff had been telling her to call for assistance, but Resident #1 had not been doing that. She stated that the facility staff placed a sign on the resident's wall to even remind her. She stated that she would walk in her room, and Resident #1 would be in her bathroom. She revealed that she often worked the hall that the resident was on, and that Resident #1 thought she was independent. She stated that she knew how to access the care plans for each resident. During an interview on 05/10/2024 at 10:45 AM., CNA C revealed that Resident #1 had been transferring by herself, even though staff asked her not to, she still would. She stated that Resident #1 used to transfer without assistance, and she still thought that she could. She stated that they would take Resident #1 to the bathroom, and she would ask facility staff to leave and then would transfer back to her wheelchair by herself. She stated that she knew how to look up the care plans. During an interview on 05/10/2024 at 11:30 AM., the DON confirmed Resident #1 required assistance x1 with transfers. Her expectations were that all staff review the care plans that are individualized to each resident and that covers their needs. She revealed that this resident was able to transfer with supervision previously, but that she required assistance with transfers at the time of the fall. A copy of the policy related to Care Plans was requested on 05/10/2024 at 1:00 PM, the facility stated that they use the RAI manual for guidance on Care Plans. Record review of CMS RAI Version 3.0 Manual last revised October 2023 revealed: the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment.

Based on interview and record review, the facility failed to ensure professional staff were licensed for 1 of 41 nursing staff (Staff A) reviewed. Staff A's LVN license had not been renewed as of [DATE] causing her LVN license to be delinquent. This deficient practice could place residents at risk of having receiving care from unlicensed staff to provide proper medical care. Findings included: Record review of personnel files indicated Staff A (LVN) nursing license expired on [DATE]. Hire date [DATE]. Staff A had no disciplinary actions against her from the facility. Record review of the License from Texas Board of Nurse Examiners Staff A had an original licensure issue date of [DATE] with a delinquent effective [DATE], with no previous disciplinary actions. Record review Daily Assignment Sheets from [DATE] to [DATE] indicated 21 days in [DATE] days in February 2024, 19 days in [DATE], and 7 days in [DATE]. Staff A was 1 of 4 nurses present on the floor during those times. In an interview on [DATE] at 2:10 pm, the Human Resources Manager (HRM) stated that it was her responsibility for checking the nurses' licenses monthly, stating I'm responsible and just somehow missed this one. In an interview on [DATE] at 4:50 pm the Director of Nursing (DON) stated that the person responsible for checking licensed staff licensure was HRM. The DON stated there was no risk to the residents other than staff having a delinquent license, further expressing that DON believed Staff A was competent in her skills of assessment, medication administration and other nursing duties. The DON said that Staff A told her that she thought her license was expiring next year. In an interview on [DATE] at 7:15 pm, the Administrator (ADM) revealed that the HRM was responsible for checking for expired licenses each month and giving a report to the DON. Record review of facility policy labeled Abuse, Neglect and Exploitation dated [DATE] revealed: Background checks: For any licensed professional applying for a position that may involve direct contact with resident, his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicant's license. The policy did not indicate that the professional license would be checked annually for current standing. Staff A could not be reached for interview as of [DATE].

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure Dietary Aide A wore effective hair restraints while preparing lunch. This failure could affect residents by placing them at risk for food borne illness. Findings included: Observation on 01/25/2024 at 11:00 AM revealed Dietary Aide A preparing the lunch meal trays on the line and placing them on a hall meal cart. Her hair was long, down her back and when she turned it brushed up against the meal cart,; it was not covered by a hair net. Interview with Dietary Aide A on 01/25/2024 at 11:15 AM revealed she forgot to put on a hair restraint while she was serving food. She stated she was supposed to wear a hair restraint in the kitchen and had received training on wearing a hairnet. She revealed that this failure would place the residents at risk for hair in their food. Interview with the Dietary Manager on 01/25/2024 at 11:30 AM, revealed that, her staff was trained and instructed to always wear hair nets when in the kitchen. She reported that she was going to do additional in-service with the staff member. She revealed that this failure was against their policy and that the failure could create unsanitary conditions. Review of the policy, Food and Nutrition Services Policy and Procedures dated February 2018 revealed . Hairnets or hair restraints and beard nets or beard restraints are in place while in the food preparation areas. Review of the US Food and Drug Administration 2017 Food Code reflected, Hair Restraints 2-402.11 Effectiveness .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles

Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for one of 1 resident (Resident #) reviewed for enteral nutrition. RN D failed to check placement of Resident #17's g-tube before starting the medication administration via g-tube feeding as required to avoid medical complications. This failure could place residents at risk for aspiration pneumonia and ineffective medication absorption. Findings include: Record review of Resident #106's face sheet, dated 11/17/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #106 had diagnoses which included dementia (problems with thinking, memory, and behavior) dysphagia (difficulty swallowing), muscle wasting, severe protein calorie malnutrition (inadequate intake of food as an essential source of protein, calories, and other essential nutrients). Record review of Resident #106's Quarterly MDS assessment, dated 10/18/23, reflected the resident required a g-tube (a tube place through the abdominal wall and directly into the stomach for all his medication administration and nutritional intake). Record review of Resident #106's physician orders, dated 11/17/23, reflected an order to flush Resident 106's g-tube with 30 cc of water via his g-tube prior to and after medications administration. Record review of Resident #17's care plan dated revised 3/22/23, reflected Resident #106 required g-tube feedings related to swallowing difficulties. The goal was for the resident to remain free of complications of tube feeding through the next review date. One intervention was to check placement and patency of feeding tube before each feeding or medication administration. Observation of medication administration for Resident #106 on 11/16/23 at 8:00 a.m. revealed LVN B did not check residual or placement before administering the resident's 30 cc bolus of water. She measured out 30 cc of water in a medication cup. LVN B did not check residual on the g-tube feeding (to avoid the risk of regurgitation and aspiration). LVN B proceeded to give the medication to Resident #106. After the administration of the 30 cc of water LVN B stated he made a mistake and he should have checked for placement of the g-tube before administration of the medication . In an interview with LVN B on 11/16/23 at 8:00 AM, he stated he failed to check placement and residual before he administered Resident #106 medication through the g-tube. He explained the placement should be checked to ensure that the tube was in the resident's stomach . LVN B said he forgot to check for placement because he was nervous. He said failure to do so could result in aspiration or infection . During an interview with the ADON on 11/16/23 at 1:41 p.m., revealed she expected all nurses to follow the facility policy in administering medication via g-tube which included checking placement and residual to ensure the tube was still in the stomach and the resident's stomach was not too full. Record review of the facility policy on g-tube feeding, dated 2/10/2020, reflected, .enteral tube placement must be checked by auscultation (listening to the gastric sound with a stethoscope) checking residual, or both prior to administering a type of medication or fluid into the tube. Record review of Fundamental of Nursing Ninth Edition, , dated 2017, reflected the following: .Steps 14. Assess gastric residual, Draw up 30 cc's of air into a 60 cc syringe, connect to feeding tube, and flush with air. Then pull back slowly to aspirate gastric contents.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 9 of 9 residents (Residents #40, #33, #36, #130, #68, #49, #26, #124 and #145) reviewed for pharmacy services. The facility failed to accurately monitor and document controlled drugs for 9 residents with medications stored on 1 of 4 Medication carts (2300 hall medication cart) reviewed for narcotic reconciliation. This failure could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes, and drug diversion. Findings included : 1. Record review of Resident # 33's physician orders, dated 11/17/23, reflected Pregabalin 100 mg 2 capsules two times a day. Record review of Resident #33 's MAR reflected Resident #40 had received Pregabalin 100 mg 2 tablets at 6:30 AM. Record Review of Resident # 33's narcotic count sheet for Pregabalin (a controlled drug for nerve pain)100 mg reflected the documented count of the Pregabalin 100 mg was 78 capsules. Observation of the medication card on 11/17/23 at 11:00 AM which contained the Pregabalin s revealed a total count of 76 capsules. In an interview with Resident #33 on11/17/23 at 11 :30 AM, she stated she believed she had all of her medications that morning . 2. Record review of Resident # 36 physician orders, dated 11/17/23, reflected Norco 10/325 mg 1 every 4 hours as needed for pain and Alprazolam 0.5 mg 1 tablet 5 times a day. Record review of Resident # 36's medication administration record reflected she received Alprazolam 0.5 mg and Norco 10/325 mg at 6:52 AM. Review of the narcotic count sheets at 10:15 AM revealed Alprazolam 0.5 mg count was 80. Observation of the Card on 11/17/23 at 11:00 AM containing the alprazolam 0.5 mg was 79. Review of the narcotic count sheet for the Narco 10/325 mg was 80 and observation of the medication card containing the narco revealed there were 79 tablets. 3. Record review of Resident # 40's physician orders dated 11/17/23, included the following Methadone10 mg 21/2 tablets every 8 hours. Record review of Resident ID #40 's MAR on 11/17/2023 at 10:15 AM revealed Resident ID #40 had received Methadone 10 mg tablets 2 1/2 tablets at 7:30 AM. Record Review of Resident # 40's narcotic count sheet for Methadone 10 mg at revealed the documented count of the Methadone 10 mg was 61 doses (2 1/2 tablets). Observation of the medication card containing the Methadone on 11/17/23 at 10:15 AM revealed a total count of 60 prefilled doses. In an interview with Resident ID # 40 at 3:30 PM she stated she believed she had all of her medications that morning. 4. Record review of Resident #130's active physician orders as of 11/17/23, included the following controlled drug Hydrocodone/APAP 10/325 mg 1 by mouth 3 time daily. Record review of the Resident ID #130's MAR on 11/17/23 at 10:15 AM revealed Resident ID #130 had received Hydrocodone 10/325 mg 1 tablet by mouth at 7:37 AM. Record review of Resident ID #130's Narcotic count sheet for Hydrocodone/APAP 10/325 on 11/17/23 at 10/15 AM revealed the documented count of the Hydrocodone/APAP mg was 20 tablets. Observation of the medication card containing the Hydrocodone/APAP 10/325 mg on 11/17/23 at 10:15 AM revealed a total count of 19. 5. Record review of Resident #68's active physician orders as of 11/17/23, included the following controlled drugs Lorazepam 1 mg 1 tablet 3 times a day routinely and every 4 hours as needed for anxiety. Record review of the Resident ID #68's MAR on 11/17/2023 at 10:15 AM revealed Resident # 68 had received 1 Lorazepam 1 mg by mouth at 8:00 AM. Record review of Resident ID #68's narcotic count sheet for Lorazepam 1 mg capsules on 11/17/23 revealed the documented count of the Lorazepam tablets was 49 tablets. Observation of the medication card on 11/17/23 at 10:15 AM containing lorazepam tablets revealed a total count of 48 tablets. 6. Record review of Resident #49's active physician orders as of 11/17/2023, included the following controlled drugs Alprazolam 0.25 mg 1 by mouth 2 times a day and every 4 hours as needed for anxiety. Record review of the Resident ID 49's MAR on 11/17/23 revealed Resident ID #4 had received Alprazolam 0.25 mg at 8:00 AM Record review of Resident #49's narcotic count sheet for lorazepam 0.25 mg tablets on 11/17/2023 at 10:30 AM revealed the documented count was 26 tablets. Observation of the medication card on 11/17/23 at 10:30 AM containing the Alprazolam 0.25 mg tablets revealed a total count of 25 tablets. 7. Record review of Resident # 26's active physician orders dated 11/17/23 revealed orders for Lorazepam 2 mg three times daily and every 4 hours as needed for anxiety and clonazepam 1 mg 2 times a day, and Hydrocodone /APAP 5/325 mg 1 every 6 hours as needed for pain. Record review of Resident # 26's MAR revealed had received: Lorazepam 2 mg at 7:48 AM, Clonazepam 1 mg, at 7:48 AM and Hydrocodone / APAP 5/325 mg at 7:48 AM Review of the narcotic count sheet for Resident #26's Lorazepam 2 mg revealed a count of 52 tablets. Observation on 11/17/23 at 10:15 AM revealed There were 51 tablets of Lorazepam 2 mg in the medication card., Clonazepam Narcotic sheet showed a count of 20 and there were 19 of the Clonazepam tablets in the card. 8. Record review of Resident #124's active physician orders as of 11/17/2023, included the following controlled drugs Lyrica 100 mg 1 tablet 2 times daily. Record review of the Resident 's #124's medication administration record on 11/17/23 at 8:45 AM PM revealed Resident ID #124 had received Lyrica at 8:45 AM. Record review of Resident #124's narcotic count sheet for Lyrica 100 mg tablets on 11/17/2023 at 10:30 AM revealed the documented count was 49 tablets. Observation of the medication card containing Lyrica 100 mg on 11/17/23 at 10:15 AM revealed a total count of 48 tablets. 9. Record review of Resident #145's active physician orders as of 11/17/2023, included the following controlled drugs Alprazolam 5 mg 2 tabs underneath the tongue 2 times daily. Record review of Resident 's #124's medication administration record on 11/17/2020 at 10:30 AM revealed Resident ID #124 had received Alprazolam 5 mg tablet 2 tabs at 8:45 AM. Record review of Resident #124's narcotic count sheet for Alprazolam 5 mg on 11/17/2023 at 10:30 AM revealed the documented count was 78 tablets. Observation of the medication card containing Lyrica 100 mg on 11/17/23 at 10:15 AM revealed a total count of 76. In an interview and observation with LVN at 10:10 AM, she stated she had not signed out for the medication on the narcotic sheet at the time of administration as she should have done, and had only recorded the time of administration when she administered the medications. She stated she was signing for the medications at that time. She stated the proper procedure for administration of any narcotic was to sign out on the narcotic control count sheet for the drug immediately after administering the medication. She stated she was training a new nurse at the facility and had just started at the facility today, and she was in a hurry and failed to sign the controlled drug sheet upon administration of her narcotics during the 8:00 AM medication pass . She stated this could result in a medication error. An interview with the ADON on 6/22/2020 at 3:00 PM revealed she expected nurses to sign for controlled medication immediately when administering them , and to count narcotics with the oncoming nurse at the end each shift. She stated she did not know LVN C had not signed for her controlled drugs when administering them. She stated she did not know why LVN C would not sign for her narcotics immediately upon administering them and would in-service her immediately on the facility's-controlled medication procedure. She stated the failure to sign for narcotics could result in a medication error. In a record review of the facility's Policy and Procedure, , dated 2018, titled Storage of Controlled Medications, documented [in part]: Medications classified by the Drug Enforcement Administration as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility as required by state, federal and other applicable laws and regulations. Agency Disposition of controlled substances is maintained on the sheet supplied by the pharmacy for all schedule 2,3,4, and 5 controlled substances. Entries are to be made in pen each time a controlled substance is used. The nurse administering the medication will record the following information: date and time drug is administered, amount of drug administered, remaining balance of drug, and signature of nurse administering drug. If the pharmacy does not provide a controlled substance audit sheet, the nursing staff will utilize the facility's-controlled drug audit sheet and fill in all of the required information from the prescription label of the medication audited.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (2300 hall med cart) reviewed for medication storage . The facility failed to ensure the 2300 hall medication cart did not contain loose pills. This failure could place residents at risk of receiving incorrect medications or ineffective therapeutic doses. The findings include: An observation on 11/17/23 at 10:00 AM of the 2300 Hall Medication Cart revealed the second drawer contained several unidentified pills littering the bottom of the drawer. In an interview and observation with LVN C on 11/17/23 at 10:10 AM, she stated it was each nurse's responsibility to see the medication carts were clean and orderly. She stated her cart did not normally contain loose, unidentified pills. She stated she had not checked the cart for cleaning today. She stated she was training a new nurse and had not had time to clean the cart the medications and the loose pills were due to the cart containing so many medication cards. She denied knowledge of what pills were laying in the bottom of the drawer. She stated unidentified pills laying in the med cart could result in a drug diversion, or residents not receiving the correct dosage of medication. In an interview on 11/17/23 at 10:45 AM, ADON B revealed it was each nurse's responsibility to ensure medication carts were kept clean. She stated it was her expectation that drugs should be stored in the original labeled packaging and nurses be responsible for cleaning their own carts. She stated carts were checked by the pharmacy consultant during their monthly visit. Record review of the facility policy titled Storage of Medications, effective March 2011, reflected in part: Procedures: N. Medication storage areas are to be kept clean, well-lit, and free of clutter. O. Medication storage conditions are monitored by the consultant pharmacist.

Based on observation, interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain clinical records on each resident that were complete and accurately documented for 1 of 11 residents (Resident #4) reviewed for clinical records. The facility failed to ensure Resident #4's electronic record reflected the residents skin conditions including the appearance, and treatment. This failure could place residents at risk of worsening skin integrity and decline in comfort level . The findings include: Record review of Resident #4's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Acute and Chronic Respiratory Failure,(acute respiratory failure is a short-term condition. It occurs suddenly and is typically treated as a medical emergency. Chronic respiratory failure is ongoing. It develops gradually and requires long-term treatment.) Heart Disease, Seizure Disorder, (epilepsy is a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures.) Obesity, Edema, (swelling caused by too much fluid trapped in the body's tissues.) Anxiety, Paralytic Gait, (a type of spastic gait in which the legs are usually slightly bent at the hip and in an adducted position) and Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture.). Record review of Resident #4 electronic record for skin assessment and skin conditions reflected no accurate and sufficient information for staff to provide and maintain Resident #4's skin integrity including progress notes, MD orders or MDS Assessment. In a Record Review of Resident #4's Nursing Home Quarterly MDS Effective 10/01/2023, revealed Cognitive Patterns reflected a BIMS summary Score of 13, which indicated the resident was cognitively intact. Under Section M Skin Conditions was checked, no skin conditions were present. Interview and observation on 11/15/2023 at 09:25 AM, CNA #B observed Performing skin and peri care for Resident #4. She showed a tube of cream named: Renew (PERIPROTECT skin Protectant Moisture Barrier Cream). She said she had been using this cream to affected skin areas. CNA #B revealed she had been doing Resident #4's peri and skin care for at least for a couple of months. CNA said she applied this cream to his skin for comfort to all areas which included the peri area, upper back, folds under breasts, groins, abdominal folds, buttock folds, pubic area, lower abdomen, upper inner thighs, right front shoulder and neck fold. In an interview on 11/16/2023 at 4:45 pm, the DON said the barrier cream on his skin areas would not be harmful due to Resident #4 having dry skin. In an interview on 11/16/2023 at 5:00 pm, with Treatment Nurse A revealed she believed he had chronic eczema. When asking for her wound care notes she said she could not provide before exit but had one picture in system from 10/27/2023 of area on top of back. She said did not have measurements or notes regarding Resident #4's skin. Writer requested Policy and procedure on skin care and documentation. The Policy for Skin Care was not provided before exiting facility. In an interview with the RN-Case Mix Manager on 11/17/2023 at 11:00 AM revealed she relied on the staff that do direct care of residents to report and maintain records that she would review to update the MDS Assessment. She said she was positive the MDS had not identified skin issues for Resident #4.

Based on Observation, interview and record review the facility failed to ensure the MDS assessment accurately relected the resident's status for 1 of 11 resident (Resident #4) reviewed for assessments. The facility failed to address skin conditions under Section M (Skin Conditions) : This failure could place residents at risk of worsening of skin conditions. The findings include: Record review of Resident #4's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Acute and Chronic Respiratory Failure, (acute respiratory failure is a short-term condition. It occurs suddenly and is typically treated as a medical emergency. Chronic respiratory failure is ongoing. It develops gradually and requires long-term treatment.) Heart Disease, Seizure Disorder, (epilepsy is a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures.) Obesity, Edema, (swelling caused by too much fluid trapped in the body's tissues.) Anxiety, Paralytic Gait, (a type of spastic gait in which the legs are usually slightly bent at the hip and in an adducted position) and Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture.). Resident #4 Record Review of Resident #4's Nursing Home MDS Effective 10/01/2023 in Section C Cognitive Patterns a BIMS summary Score of 13 (cognitively intact). Under Skin Conditions was not checked. Under skin conditions, no skin conditions were present. Interview and observation with Resident #4 on 11/15/2023 at 09:25 AM, Resident #4 said he had skin issues for an extended period. Observation of the skin areas revealed affected skin lesions covering a large majority of his body's torso and private areas which included the peri area, upper back, folds under breasts, groins, abdominal folds, buttock folds, pubic area, lower abdomen, upper inner thighs, right front shoulder and neck fold . Interview and observation on 11/15/2023 at 09:25 AM, CNA #B observed Performing skin and peri care for Resident #4. She showed a tube of cream named: Renew (PERIPROTECT skin Protectant Moisture Barrier Cream). She said she had been using this cream to affected skin areas. CNA #B revealed she had been doing Resident #4's peri and skin care for at least for a couple of months. CNA said she applied this cream to his skin for comfort to all areas which included the peri area, upper back, folds under breasts, groins, abdominal folds, buttock folds, pubic area, lower abdomen, upper inner thighs, right front shoulder and neck fold. In an interview with RN-Case Mix Manager on 11/17/2023 at 11:00 AM said she relied on the staff that do direct care of Resident's to report and maintain records that she would review to update MDS Assessment. She said she was positive that the MDS had not been identified for skin issues.

Based on observation, interview and record review the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift that was in a clear and readable format and in a prominent place readily accessible to residents and visitors for 1 of 4 reviewed for nursing services. 4 The facility failed to update and post the daily nurse staffing information on 11/17/2023. This failure could place residents at risk of not having access to information regarding staffing data and facility census. The findings include: Observation on 11/17/2023 at 2:30 PM revealed the daily nurse staffing pattern was not posted on the front door in the location designated for it. In an interview on 11/17/2023 at 2:35 PM, the ADON stated, I'm sorry I failed to change the staffing today because I've been so busy and have not gotten around to it yet. In an interview on 11/17/23 at 2:53 PM, the Administrator stated, My expectation is that the ADON follow our policy regarding staffing posting. he further stated, The staffing posting is checked on a daily basis by the DON, however she's out today and I failed to check it today. He said not posting the information would give the public inaccurate information. Record review of a facility policy titled, Nurse Staffing Posting dated, 11/04/2017 reflected in-part: 1. The nurse staffing information will be posted on a daily basis and will contain the following information. ? the total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift ? Registered Nurses ? Licensed Vocational Nurses ? Certified Nurse Aides 2. The facility will post the nurse staffing data at the beginning of each shift.

Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate treatment and services to prevent complications for one (Residents #1) of three residents reviewed for tube feedings. The facility failed provide the necessary care and services to Resident #1 for his gastronomy tube. He was left in flat position while receiving enteral feeding. Resident #1 was found gurgling and unable to respond verbally. Resident #1 was transferred to the hospital where he was found to have aspiration pneumonia with approximately 50 cc of secretions suctioned out of his lungs. He passed away on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to monitor the effectiveness of their Plan of Removal. These failures placed residents at risk for perforation of the g-tube, aspiration pneumonia, replacement of the g-tube, hospitalization , or even death. Findings included: Review of Resident #1 face sheet dated [DATE] revealed he was a [AGE] year-old male admitted on [DATE] to the facility. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 which indicates severe cognitive impairment. He receives enteral feeding through g-tube. Resident #1 required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and two-person assist with transfer. He was always incontinent of bowel and bladder. Review of Resident #1's comprehensive care plan, dated [DATE], revealed the resident requires the use of a g-tube and at risk of aspiration, weight loss, and dehydration. Its goal was for Resident #1 to be free of aspiration through the review date. The interventions include to elevate head of bed 45 degrees or as ordered by physician while feeding tube is being used for feeding and at least 30 minutes after bolus or tube feedings. Review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review reflected a signed MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's note dated [DATE] and entered at 3:45p.m reflected, Upon entry to resident's room, this nurse noted audible gurgling; resident head of bed was flat. This nurse immediately raised head of bed 90 degrees: resident unable to verbalize; normally resident is a/o X3 (alert and oriented to name, place and time). Skin cool and damp. This nurse had aide sit with resident; this nurse instructed LVNS to contact emergency transport. PERRLA (pupils equal, round and reactive) noted; vitals as follows: BP ,d+[DATE], T97, P72, R20, 02 stat 92%on RA (room air) LVNS called in report to the hospital: this nurse attempted to contact the resident's son; no answer; left vm (voice message) to call asap for report. This nurse made DON aware of transport; NP agreeable for transport as well; awaiting emergency transport arrival, will continue to monitor. Review of hospital record on admitted d [DATE] reflected, 73- year-old male was in the nursing home when he was found to be lying flat in bed receiving a NG tube feeding. The patient was found with vomiting of secretions. Upon arrival to the hospital, the patient was suctioned out approximately ,d+[DATE] cc of yellow to white secretions oropharynx . Patient has been treated with dual therapy antibiotics for aspiration pneumonia. Chest x-ray does show some infiltrates that may be reflective of pneumonia, verses [CONDITION(S)] . Resident passed away about 2 weeks after admission on [DATE]. During interview with LVNA on [DATE] at 3:00p.m and [DATE] at 2: 49p.m, she said she was the nurse who first saw Resident #1 on [DATE] (day of the incident) lying flat on the bed while receiving enteral feeding through a g-tube. She stated the resident was making an audible gurgling (bubbly sound). She said the resident was clammy (skin was cold) and the head of bed was flat. She thinks Resident #1 has been in that condition for a while because of the cold touch on his skin and overall appearance. LVNA explained Resident #1 was normally alert, oriented to name, place and time. She immediately notified another nurse to call 911 to transfer resident to the hospital. On [DATE], she came for the ,d+[DATE]p.m shift on Resident #1 hall. She said it was a hectic and chaotic day because of Covid-19 residents. LVNA explained it took 1 hour for the shift change with LVN B. She said at round 3:,d+[DATE]:30p.m she was making rounds and saw the resident. She went to the room with CNAD. LVNA stated she tried to find out what happened, but no one knew. The aides she noted, acted like they didn't know what to do. She said she thinks the aides were not trained. LVNA said she informed the DON about Resident #1 condition. She was asked why she didn't do an incident report based on record of accident/incident reports. LVNA said it was a busy day and she didn't have any reason for not doing incident report. She went on to say there was a mistake made that day, but she was not sure by who. LVN A said LVNB was the nurse responsible for Resident #1 before she came in In an interview with LVNB on [DATE] at 11: 43a.m, she said she was responsible for Resident #1 on the morning shift on [DATE]. LVNB explained she does not work regularly but periodically as a substitute nurse. She stated she took the resident temperature around 10:15a.m. and gave him his medication. LVNB said Resident #1 was his usual self and the head of bed was elevated as required ,d+[DATE] degrees. She recalled him asking for water like he almost always does when she talks to him. She told him, he was NPO (nothing by mouth) and could not have water by mouth. LVNB did not remember the last time she saw the resident on [DATE]. She said the aides normally make their final check around 1:00p.m to 2:00p.m. She did not have report of anything unusual about Resident #1 on that day. LVNB noted CNAC was the aide on her shift on [DATE]. She said she has not received in-services on tube feeding care and management since the incident on [DATE]. During interview with CNAC on [DATE] at 4:34p.m, she said she was the aide responsible for Resident #1 on the morning of[DATE]. CNAC was very vague and denied leaving Resident #1 flat. She explained she made final rounds around 1:30 pm on a given morning shift. CNAC said she believe she did the same with Resident #1 and there was nothing unusual that day. CNAC stated she knew to elevate Resident #1 bed ,d+[DATE] degrees. She said she was not in the facility when the resident was transferred to the hospital. Interview with CNAD on [DATE] at 12:15p.m, revealed she went to Resident #1's room with LVNA on [DATE] at about 3: 15p.m after arriving for the evening shift. She explained Resident #1 was lying almost flat, gurgling and struggling to breathe. LVNA told her to stay with Resident #1 while she goes to tell another nurse to Call 911. CNAD said the resident was transferred to the hospital within 20 minutes. She did not recall having in-services on g-tube feeding since the incident on [DATE] and initial entrance of the surveyor on [DATE]. During interview with DON on [DATE] at 3:51p.m, she said she did not know about the incident with Resident #1 on [DATE]. She explained she became aware when the surveyor made an entrance to facility on [DATE]. The DON was reminded that LVNA documented Resident #1 change of condition and transfer to the hospital. The DON stated LVNA said she informed her. She said she will not dispute that but looked over her phone records and text messages without evidence of such notifications. She explained she looked at her texting records and noticed that LVNA texted her all day on [DATE] but did not mention the incident. She noted that was why the incident was reported to the State. She said she was not aware of the incident. In an interview with the Administrator on [DATE] at 3:51p.m, he was asked the reason the incident with Resident #1 was not reported. He said they didn't know about it until the surveyor came to the facility on [DATE]. An Immediate Jeopardy was identified on [DATE] at 5:00p.m. The Administrator was notified on [DATE] at 5:00p.m of the IJ. The plan of removal was requested at that time and the IJ template was given to the Administrator. The facility's plan of removal accepted on [DATE] at 3:00p.m. Plan of Removal [DATE] This plan of removal represents the facility response to the Immediate Jeopardy notification the Center received at 5:30 pm on [DATE] related to failure to elevate head of bed of a resident with continuous G-Tube feeding and was found gurgling and unresponsive and was transferred to hospital and diagnosed with aspiration Pneumonia and was placed on Hospice services and expired on [DATE]. Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur, or recur Immediate Actions Taken by the Facility This incident occurred on [DATE]. In response to this alleged allegation, On [DATE] the DON completed rounds validating that the head of bed was elevated on all tube fed residents. On [DATE] LVN S provided in-service education to Nurses and Certified Nurse assistances on Clinical Practice Guidelines: Care of Tube Feed Resident which includes elevation of the HOB to prevent aspiration pneumonia. Tube Feeding Skills validation was conducted on [DATE] with the Licensed Nurses by the DON or designee to validate the care of positioning a tube fed resident during care: turning off tube feeding, lowering head of bed, care provided, elevating head of bed then turning on tube feeding. Tube Feeding Skills validation was conducted on [DATE] with the Certified Nurse Aides by the DON or designee to validate the care of positioning a tube fed resident during care: turning off tube feeding, lowering head of bed, care provided, elevating head of bed then turning on tube feeding. All the above education and or skills competencies will be completed on [DATE] and no staff will be allowed to return to work until their required education is completed. Identification of Residents Affected or Likely to be Affected: All Enteral tube fed residents have the potential to be affected by this potential alleged practice. On [DATE], [DATE] and [DATE], DON using the Tube feeding QAPI Audit tool validate that 4 like residents were not affected by this alleged deficient practice. Actions to Prevent Occurrence/Recurrence: On Wednesday [DATE], Thursday [DATE], and Friday [DATE] DON validated that the four residents that have enteral feeding had their head of bed elevated using the Tube feeding QAPI audit tool. On [DATE] in-service education conducted by Administrator on abuse and neglect with all staff to include a post-test. The DON or designee will use the tube feeding QAPI Validation Checklist Tool 3 times per shift for two weeks to validate the care of tube fed residents. The DON will use the INTERACT 4.0 QAPI Audit tool for all residents transferred to hospital to evaluate care and services to determine if training or follow up education is needed. Upon hire licensed nurses and certified nurse aides complete a Skills Validation which includes the care of tube fed residents; turning off tube feeding, lowering head of bed, care provided, elevating head of bed then turning on the tube feeding. This will be accomplished during orientation before employee is released to work on their own. This will be verified by DON. Date Facility Asserts Likelihood for Serious Harm No Longer Exits [DATE] Review of the facility policy on care of g-tube dated [DATE] reflected, Resident will remain free of complications related to use of a feeding tube. Tube feeding should be consistent with current standards of practice and overall therapeutic goals of the incident and delivered in an ethical manner. Its prevention of mechanical complications includes: 1) Keep head of bed (HOB) elevated ,d+[DATE] degrees during feeding, keep HOB elevated for 3 minutes after feeding 2) If necessary, to lower the HOB for a procedure or a medical contraindication, return the patient to an elevated HOB position as soon as feasible . To verify the facility implemented their plan of removal, the following observations, interviews and record reviews were conducted: Observations of the three residents with g-tube on [DATE] at 4:10p.m revealed they were properly position for feeding. Record review of in-services dated from [DATE] through [DATE] revealed the staffs were verified to be in-serviced on tube-feeding and elevation of the head of bed.before start of their shifts. During interviews on [DATE] from 3:18pm to 4:01p.m with LVNA, RNG, LVNE, LVNF, LVNS, LVNH, LVNI, LVNJ, LVNK. They stated they received training on how to reposition residents on g-tube feeding. They were also instructed to ensure the head of bed was elevated ,d+[DATE] degree during g-tube feeding During interviews on [DATE] from 3:18p.m to 4: 01p.m with CNAC, CNAL, CNAM, CNAO, CNAP, CNAQ, and CNAR. They said they received training/in-services on the proper way to position residents receiving g-tube which was to elevate the resident's head of bed ,d+[DATE] degrees On [DATE] at 5:42 p.m., the Administrator was notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to monitor the effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility's Administrator and Director of Nurses failed to utilize facility resources effectively to ensure 1 of 7 residents (ID #1) allegations of sexual abuse was investigated and reported, that all other residents in the facility were protected from future abuse. The Administrator and DON failed to implement the facility's abuse and neglect policy and procedure. On 9/10/10 at 5:15 PM the local MHMR facility notified the facility's Social Worker that resident ID #1 had made an allegation that she was sexually abused by CNA "A". The facility's SW informed the Adminsitrator and DON on 9/10/10 at 5:15 PM. The facility Administrator did not identify this allegation as something they needed to investigate.They did not investigate the allegation, report the allegation to the state office, or suspend the alleged perpretrator pending the investigation findings. On 9/11/10 at 11:30 PM, CNA "A" was observed by the surveyor to be performing direct resident care at the facility. These failures placed all other residents at the facility at risk for abuse. An Immediate Jeopardy (IJ) situation was identified on 9/10/at 5:15 PM. After implementation of a plan of removal, the IJ was removed on 9/15 10 at 3:25 PM. The facility remained out of compliance at a level of no actual harm with a potential for more than minmal harm, widespread, because the facility had not completed their investigation or monitored for effectiveness. The facility's failure could affect all 79 residents by increasing their risk of sexual abuse. The findings included: Review of Resident #1's admission sheet revealed she was a [AGE] year old female admitted to the facility from a state hospital on [DATE]. Record review of Resident ID #1's September 2010 physician's orders [REDACTED]. Record review of Resident ID #1's admission MDS dated [DATE] revealed the resident had a short term memory problem but knew the location of her room, that she was in a nursing home, and the current season. It identified the resident as resisting care at least 4-6 days per week with her behavior not being easily altered. Record review of Resident ID #1's undated care plan documented she believed staff members were her husband. There was no documentation regarding any previous complaints or allegations of rape made by Resident ID #1 at the facility. Record review of resident ID #1's physician's orders [REDACTED].#1 was agitated and physically aggressive to staff and other residents. She was referred to a local mental health facility for evaluation. Record review of an assessment referral form from a local MHMR (Mental Health Mental [MEDICAL CONDITION] Center)clinician dated 09/08/10 at 5:45 PM documented resident ID #1 stated, "CNA "A" raped her". In an interview 9/13/10 at 2:30 PM the facility Social Worker revealed, that the local MHMR center notified her on 09/10/10 after 5 PM that Resident ID #1 had reported being raped on the night shift on 9/8/10 or 9/9/10 and that the caller reported the incident to APS (Adult Protective Service). The facility Social Worker further stated, "I informed The Administrator and DON of the allegation at 5:15 PM on 9/10/10." Observation on 9/11/10 at 11:30 PM, revealed CNA "A" was working at the facility, performing direct resident care. In an interview 9/11/10 at 11:35 PM, LVN "B" stated the staff on duty included CNA "A". she further stated, "all of the CNA's work well and I have had no complaints from the staff or residents of any type of abuse or any other complaints". LVN "B" was not aware of any allegations of rape. In an interview on 9/11/10 at 11:50 PM CNA "C" revealed, she had received no complaints from residents or family members of abuse of any kind. In an interview on 9/12/10 at 12:35 AM LVN "D" revealed, she had not received any complaints of abuse from anyone. She further revealed, Resident ID #1 thought she was married to another resident, and that LVN "D" was her daughter. On 9/13/10 at 11:25 AM, the surveyor notified the local Police department of the alleged rape and Resident #1's current location. In an interview on 9/13/10 at 11:40 AM at a local Mental Health Facility Resident ID # 1 revealed, she had been raped five days ago at the nursing facility on the night shift by CNA "A" She stated, "I did not scream or yell and did not tell anyone. He put me across the bed he did not take my clothes off or his clothes off. I don't know what time it was, but it was dark, then I had lunch. He gave me medicine so I was drowsy and could not talk". In an interview on 9/13/10 at 11:55 AM, the local Police Officer wanted to know why he was just now being notified about resident ID #1's rape allegation and stated, "we should have been the first ones called when the victim reported rape." and revealed no one else had reported the allegation. In an interview on 09/13/10 at 3 PM, resident ID #1's primary care physician stated he was not aware of resident ID #1's allegation of rape. He further stated he had not been informed of any behavioral issues or of her transfer to the local inpatient psychiatric facility. In an interview on 9/13/10, at 3:40 PM, facility Administrator revealed, she had not reported or investigated the incident. And stated, if the allegation had occured at the facility "we would have done an immediate investigation. We didn't find out about it until APS told us on 9/10/10 after 5 PM, and we knew it didn't happen. She has [MEDICAL CONDITION] all the time. I knew it was not true. I didn't need to investigate it." In an interview 9/13/2010 at 3:45 PM the facility Director of Nurses (DON) stated, "We all knew he didn't do it. At no time were any residents in danger from him. Are we supposed to suspend someone anytime someone says they did something?" In an interview 9/15/2010 at 9:20 AM CNA "A" stated, "resident ID #1 would follow me around on a nightly basis, if she wasn't asleep. She would bring me something to eat, I told the nurses to chart it, because I was afraid I could get into trouble". He further stated, "I did not rape resident ID #1, I did not touch her, she has mental problems". Review of the facility Nursing schedule revealed CNA "A" was not scheduled and did not work 9/8, 9/9 but did work 9/10, 9/11 and 9/12 and was scheduled to work 9/13/10. Record review of the undated facility Abuse, Prohibition Policy and Procedure revealed it was updated on 01/07 and stated (in part): "Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local,. state and federal agencies, "notify criminal authorities in a timely fashion," and "Administrator or designated representative will immediately begin an investigation." It further states "The alleged abuser will be removed from the facility immediately, and not allowed in the facility, pending the outcome of the investigation." The facility Administrator and DON were notified on 9/13/10 at 4:30 PM that an immediate jeopardy situation had been identified due to the above failures. In an interview on 09/13/10 at 4:45 PM the Administrator stated the immediate jeopardy occurred because the facility did not follow their policy and procedure. She further stated the system failure involved the investigation process and stated they did not investigate the allegation. She stated she did not think anything could happen by allowing CNA "A" to continue to work at the facility because she "knows he's a nice guy", but stated allowing him to continue to work after resident ID #1's allegation could put the other residents in danger. In an interview on 09/13/10 at 4:45 PM the DON stated the immediate jeopardy occurred due to a breakdown in the policy and procedure, and because they had not followed their own policy and procedure. She further stated the system failure involved the facility's investigation process because "we just didn't do it." The DON revealed the facility should be cautious and investigate everything and stated that CNA "A" had been suspended until the investigation was complete. On 9/15/10, the facility's Administrator submitted a plan for removal which included initiating an investigation on 09/13/10 and conitinuing until completion, re-inservicing the Administrator and DON regarding the abuse/neglect policies and procedures, interviewing interviewable residents concerning CNA "A", involving the QA committed to review the response plan monthly for three months to ensure it is effective, notifiying the medical director of the IJ status, in-servicing all staff members prior to coming on shift regarding the abuse/neglect policies and procedures, developing a plan to assess resident ID #1 upon her return to the facility and develop a care plan based on her specific identified needs, educate facility staff members regarding ways to interact with the resident and the need to identify and immediately report allegations to their supervisors, developing a plan for male staff to provide care to the resident with a female staff also present, and suspending CNA "A" pending the investigation findings. The surveyor confirmed through interviews and record reviews that the facility had in-serviced the Administrator, DON, and all on-coming employees regarding the abuse/neglect policies and procedures. The surveyor also confirmed that CNA "A" was suspended pending the findings of the investigation. On 9/15/10 at 3:25 PM, the DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as widespread. The facility was continuing to in-service employees, interview residents and staff, and complete their investigation. The facility's CMS 672 Resident Census and Condition dated 09/13/10 documented a census of 79 residents.

Based on observation, interview, and record review, the facility failed to ensure 1 of 7 sampled resident's (ID # 1) allegation of sexual abuse was thoroughly investigated and reported, and that further abuse was prevented. On 09/10/10 the facility Social Worker received a call from the local MHMR and was made aware of resident ID #1 ' s allegation that she had been raped by Certified Nurses Aide (CNA) " A " on 09/08/10 or 09/09/10. The facility did not report or initiate an investigation into the allegation, and did prevent CNA " A " from having resident contact. CNA "A" continued to perform direct resident care at the facility for 3 consecutive nights, on 9/10/10, 9/11/10, and 9/12/10, after the facility became aware of the allegation. These failures resulted in an identification of an immediate jeopardy (IJ) on 9/13/10 at 4:30 PM. While the IJ was removed on 9/15/10 at 3:25 PM, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread. The facility remained out of compliance due to all active nursing staff not being inserviced regarding abuse and reporting procedures. The facility's failures could affect any of the 79 residents at the facility by placing them at risk of sexual abuse. The findings included: Review of Resident #1's admission sheet revealed she was a [AGE] year old female admitted to the facility from a state hospital on [DATE]. Record review of Resident ID #1's September 2010 physician's orders [REDACTED]. Record review of Resident ID #1's admission MDS dated [DATE] revealed the resident had a short term memory problem but knew the location of her room, that she was in a nursing home, and the current season. It identified the resident as resisting care at least 4-6 days per week with her behavior not being easily altered. Record review of Resident ID #1's undated care plan documented she believed staff members were her husband. There was no documentation regarding any previous complaints or allegations of rape made by Resident ID #1 at the facility. Record review of resident ID #1's physician's orders [REDACTED].#1 was agitated and physically aggressive to staff and other residents. She was referred to a local mental health facility for evaluation. Record review of an assessment referral form from a local MHMR (Mental Health Mental [MEDICAL CONDITION] Center)clinician dated 09/08/10 at 5:45 PM documented resident ID #1 stated, "CNA "A" raped her". In an interview 9/13/10 at 2:30 PM the facility Social Worker revealed, that the local Mental Health Mental [MEDICAL CONDITION] Center notified her on 09/10/10 after 5 PM that Resident ID #1 had reported being raped on the night shift on 9/8/10 or 9/9/10 and that the caller reported the incident to APS (Adult Protective Service). The facility Social Worker further stated, "I informed The Administrator and DON of the allegation at 5:15 PM on 9/10/10." Observation on 9/11/10 at 11:30 PM, revealed CNA "A" was working at the facility, performing direct resident care. In an interview 9/11/10 at 11:35 PM, LVN "B" stated the staff on duty included CNA "A". she further stated, "all of the CNA's work well and I have had no complaints from the staff or residents of any type of abuse or any other complaints". LVN "B" was not aware of any allegations of rape. LVN "B" further stated, "the Abuse Coordinator is the Administrator". In an interview on 9/11/10 at 11:50 PM CNA "C" revealed, she had received no complaints from residents or family members of abuse of any kind. Stated, "the Abuse Coordinator is the Administrator". In an interview on 9/12/10 at 12:35 AM LVN "D" revealed, she had not received any complaints of abuse from anyone. She further revealed, Resident ID #1 thought she was married to another resident, and that LVN "D" was her daughter. LVN "D" further stated, "the Abuse Coordinator is the Administrator". On 9/13/10 at 11:25 AM, the surveyor notified the local Police department of the alleged rape and Resident #1's current location. In an interview on 9/13/10 at 11:40 AM at a local Mental Health Facility Resident ID # 1 revealed, she had been raped five days ago at the nursing facility on the night shift by CNA "A". She stated, "I did not scream or yell and did not tell anyone. He put me across the bed he did not take my clothes off or his clothes off. I don't know what time it was, but it was dark, then I had lunch. He gave me medicine so I was drowsy and could not talk". In an interview on 9/13/10 at 11:55 AM, the local Police Officer wanted to know why he was just now being notified about resident ID #1's rape allegation and stated, "we should have been the first ones called when the victim reported rape," and revealed no one else had reported the allegation. In an interview on 09/13/10 at 3 PM, resident ID #1's primary care physician stated he was not aware of resident ID #1's allegation of rape. He further stated he had not been informed of any behavioral issues or of her transfer to the local inpatient psychiatric facility. In an interview on 9/13/10, at 3:40 PM, facility Administrator revealed, she had not reported, investigated the incident or called the police. She stated if the allegation of rape "had happened here we would have done an immediate investigation. We didn't find out about it until APS told us on 9/10/10 after 5 PM, and we knew it didn't happen. She has [MEDICAL CONDITION] all the time. I knew it was not true. I didn't need to investigate it." In an interview 9/13/2010 at 3:45 PM the facility Director of Nurses (DON) stated, "We all knew he didn't do it. At no time were any residents in danger from him. Are we supposed to suspend someone anytime someone says they did something?" In an interview 9/15/2010 at 9:20 AM CNA "A" stated, "resident ID #1 would follow me around on a nightly basis, if she wasn't asleep. She would bring me something to eat, I told the nurses to chart it, because I was afraid I could get into trouble". He further stated, "I did not rape resident ID #1, I did not touch her, she has mental problems". Review of the facility Nursing schedule revealed CNA "A" was not scheduled and did not work 9/8, 9/9 but did work 9/10, 9/11 and 9/12 and was scheduled to work 9/13/10. Record review of the undated facility Abuse, Prohibition Policy and Procedure revealed it was updated on 01/07 and stated (in part): "Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local,. state and federal agencies, "notify criminal authorities in a timely fashion," and "Administrator or designated representative will immediately begin an investigation." It further states "The alleged abuser will be removed from the facility immediately, and not allowed in the facility, pending the outcome of the investigation." The facility Administrator and DON were notified on 9/13/10 at 4:30 PM that an immediate jeopardy situation had been identified due to the above failures. In an interview on 09/13/10 at 4:45 PM the Administrator stated the immediate jeopardy occurred because the facility did not follow their policy and procedure. She further stated the system failure involved the investigation process and stated they did not investigate the allegation. She stated she did not think anything could happen by allowing CNA "A" to continue to work at the facility because she "knows he's a nice guy", but stated allowing him to continue to work after resident ID #1's allegation could put the other residents in danger. In an interview on 09/13/10 at 4:45 PM the DON stated the immediate jeopardy occurred due to a breakdown in the policy and procedure, and because they had not followed their own policy and procedure. She further stated the system failure involved the facility's investigation process because "we just didn't do it." The DON revealed the facility should be cautious and investigate everything and stated that CNA "A" had been suspended until the investigation was complete. On 9/15/10, the facility's Administrator submitted a plan for removal which included initiating an investigation on 09/13/10 and continuing until completion, re-inservicing the Administrator and DON regarding the abuse/neglect policies and procedures, interviewing interviewable residents concerning CNA "A", involving the QA committed to review the response plan monthly for three months to ensure it is effective, notifiying the medical director of the IJ status, in-servicing all staff members prior to coming on shift regarding the abuse/neglect policies and procedures, developing a plan to assess resident ID #1 upon her return to the facility and develop a care plan based on her specific identified needs, educate facility staff members regarding ways to interact with the resident and the need to identify and immediately report allegations to their supervisors, developing a plan for male staff to provide care to the resident with a female staff also present, and suspending CNA "A" pending the investigation findings. The surveyor confirmed through interviews and record reviews that the facility had in-serviced the Administrator, DON, and all on-coming employees regarding the abuse/neglect policies and procedures. The surveyor also confirmed that CNA "A" was suspended pending the findings of the investigation. On 9/15/10 at 3:25 PM, the DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as widespread. The facility was continuing to in-service employees, interview residents and staff, and complete their investigation. The facility's CMS 672 Resident Census and Condition dated 09/13/10 documented a census of 79 residents.

Based on observation, interview, and record review, the facility failed to implement their written abuse polices and procedures for 1 of 7 residents (ID #1) by failing to: A) thoroughly investigate, document the investigation, and report allegations of sexual abuse concerning resident #1 to the state agency after being notified by another agency on 9/10/10; and B) Prevent further abuse, CNA "A" continued working at the facility performing direct resident care for 3 consecutive days, on 9/10/10, 9/11/10 and 9/12/10, after the facility became aware of the allegation. These failures resulted in an identification of an immediate jeopardy (IJ) on 9/13/10 at 4:30 PM. While the IJ was removed on 9/15/10 at 3:25 PM, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread. The facility remained out of compliance due to all active nursing staff not being inserviced regarding abuse and reporting procedures. The facility's failures could affect any of the 79 Residents at the facility by placing them at risk of sexual abuse. The findings included: Record review of the undated facility Abuse, Prohibition Policy and Procedure revealed it was updated on 01/07 and stated (in part): "Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local,. state and federal agencies, "notify criminal authorities in a timely fashion," and "Administrator or designated representative will immediately begin an investigation." It further states "The alleged abuser will be removed from the facility immediately, and not allowed in the facility, pending the outcome of the investigation." Review of Resident #1's admission sheet revealed she was a [AGE] year old female admitted to the facility from a state hospital on [DATE]. Record review of Resident ID #1's September 2010 physician's orders [REDACTED]. Record review of Resident ID #1's admission MDS dated [DATE] revealed the resident had a short term memory problem but knew the location of her room, that she was in a nursing home, and the current season. It identified the resident as resisting care at least 4-6 days per week with her behavior not being easily altered. Record review of Resident ID #1's undated care plan documented she believed staff members were her husband. There was no documentation regarding any previous complaints or allegations of rape made by Resident ID #1 at the facility. Record review of resident ID #1's physician's orders [REDACTED].#1 was agitated and physically aggressive to staff and other residents. She was referred to a local mental health facility for evaluation. Record review of an assessment referral form from a local MHMR (Mental Health Mental [MEDICAL CONDITION] Center)clinician dated 09/08/10 at 5:45 PM documented resident ID #1 stated, "CNA "A" raped her". In an interview 9/13/10 at 2:30 PM the facility Social Worker revealed, that the local Mental Health Mental [MEDICAL CONDITION] Center notified her on 09/10/10 after 5 PM that Resident ID #1 had reported being raped on the night shift on 9/8/10 or 9/9/10 and that the caller reported the incident to APS (Adult Protective Service). The facility Social Worker further stated, "I informed The Administrator and DON of the allegation at 5:15 PM on 9/10/10." Observation on 9/11/10 at 11:30 PM, revealed CNA "A" was working at the facility, performing direct resident care. In an interview 9/11/10 at 11:35 PM, LVN "B" stated the staff on duty included CNA "A". she further stated, "all of the CNA's work well and I have had no complaints from the staff or residents of any type of abuse or any other complaints". LVN "B" was not aware of any allegations of rape. LVN "B" further stated, "the Abuse Cordinator is the Administrator". In an interview on 9/11/10 at 11:50 PM CNA "C" revealed, she had received no complaints from residents or family members of abuse of any kind. Stated, "the Abuse Cordinator is the Administrator". In an interview on 9/12/10 at 12:35 AM LVN "D" revealed, she had not received any complaints of abuse from anyone. She further revealed, Resident ID #1 thought she was married to another resident, and that LVN "D" was her daughter. LVN "D" further stated, "the Abuse Cordinator is the Administrator". On 9/13/10 at 11:25 AM, the surveyor notified the local Police department of the alleged rape and Resident #1's current location. In an interview on 9/13/10 at 11:40 AM at a local Mental Health Facility Resident ID # 1 revealed, she had been raped five days ago at the nursing facility on the night shift by CNA "A" She stated, "I did not scream or yell and did not tell anyone. He put me across the bed he did not take my clothes off or his clothes off. I don't know what time it was, but it was dark, then I had lunch. He gave me medicine so I was drowsy and could not talk". In an interview on 9/13/10 at 11:55 AM, the local Police Officer wanted to know why he was just now being notified about resident ID #1's rape allegation and stated, "we should have been the first ones called when the victim reported rape," and revealed no one else had reported the allegation. In an interview on 09/13/10 at 3 PM, resident ID #1's primary care physician stated he was not aware of resident ID #1's allegation of rape. He further stated he had not been informed of any behavioral issues or of her transfer to the local inpatient psychiatric facility. In an interview on 9/13/10, at 3:40 PM, facility Administrator revealed, she had not reported, investigated the incident or called the police. She stated if the allegation of rape "had happened here we would have done an immediate investigation. We didn't find out about it until APS told us on 9/10/10 after 5 PM, and we knew it didn't happen. She has [MEDICAL CONDITION] all the time. I knew it was not true. I didn't need to investigate it." In an interview 9/13/2010 at 3:45 PM the facility Director of Nurses (DON) stated, "We all knew he didn't do it. At no time were any residents in danger from him. Are we supposed to suspend someone anytime someone says they did something?" In an interview 9/15/2010 at 9:20 AM CNA "A" stated, "resident ID #1 would follow me around on a nightly basis, if she wasn't asleep. She would bring me something to eat, I told the nurses to chart it, because I was afraid I could get into trouble". He further stated, "I did not rape resident ID #1, I did not touch her, she has mental problems". Review of the facility Nursing schedule revealed CNA "A" was not scheduled and did not work 9/8, 9/9 but did work 9/10, 9/11 and 9/12 and was scheduled to work 9/13/10. The facility Administrator and DON were notified on 9/13/10 at 4:30 PM that an immediate jeopardy situation had been identified due to the above failures. In an interview on 09/13/10 at 4:45 PM the Administrator stated the immediate jeopardy occurred because the facility did not follow their policy and procedure. She further stated the system failure involved the investigation process and stated they did not investigate the allegation. She stated she did not think anything could happen by allowing CNA "A" to continue to work at the facility because she "knows he's a nice guy", but stated allowing him to continue to work after resident ID #1's allegation could put the other residents in danger. In an interview on 09/13/10 at 4:45 PM the DON stated the immediate jeopardy occurred due to a breakdown in the policy and procedure, and because they had not followed their own policy and procedure. She further stated the system failure involved the facility's investigation process because "we just didn't do it." The DON revealed the facility should be cautious and investigate everything and stated that CNA "A" had been suspended until the investigation was complete. On 9/15/10, the facility's Administrator submitted a plan for removal which included initiating an investigation on 09/13/10 and conitinuing until completion, re-inservicing the Administrator and DON regarding the abuse/neglect policies and procedures, interviewing interviewable residents concerning CNA "A", involving the QA committed to review the response plan monthly for three months to ensure it is effective, notifiying the medical director of the IJ status, in-servicing all staff members prior to coming on shift regarding the abuse/neglect policies and procedures, developing a plan to assess resident ID #1 upon her return to the facility and develop a care plan based on her specific identified needs, educate facility staff members regarding ways to interact with the resident and the need to identify and immediately report allegations to their supervisors, developing a plan for male staff to provide care to the resident with a female staff also present, and suspending CNA "A" pending the investigation findings. The surveyor confirmed through interviews and record reviews that the facility had in-serviced the Administrator, DON, and all on-coming employees regarding the abuse/neglect policies and procedures. The surveyor also confirmed that CNA "A" was suspended pending the findings of the investigation. On 9/15/10 at 3:25 PM, the DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as widespread. The facility was continuing to in-service employees, interview residents and staff, and complete their investigation. The facility's CMS 672 Resident Census and Condition dated 09/13/10 documented a census of 79 residents.